^   \                '^Vn               ^    \t>  ^                      £ 

/ Vo  \         Jf^      XCl\  LIBKAR.Y  /  j- 

J  ^     r*"///'7       ^<r  LJ  x^°  ydiv'iisn  ^  ^-^  ^     ^*7 

^           j£r  q.           v<.7                   t 


\  c%^^  /\  r^v  A  ^ 

:V'B£*VCD\  ^/aV16 

J8n  \C3/    qv/;      NP,/  «"^an  \L 
Ao    '*^*     C    C  '^o*     oMmjA<? 

i$  /\  S'tf^  /\  -  ^ 5  / 

2j     /Vn\  LIBRARY  /rn\       ^''i-'     /r 

-*          v^r-i         ~  -«»— ,          vO         L 


^  \ 

I  \ 

;,   [ 


LIBRAfLV          pn^         ^//?  p^.          LIB 

*       ~^    '       *~          ^"~^     0/" 


^<T       C     r^  ^^ 

,^      w~—«2  ,,t,y       -.      &arv  rranciscp     ^\ 


3  \  « 


\ 


•-, 


U 


LI  B  RAf^Y 


,o        L^J        r  o« 

•     ' 


V   LIB 


r 
L 


n 


LIBRARY 


r 


--          o  rQ        ^,__^        0<l  _x_         q,.        __ 

~J    <*Q      (~~t  .  /i         **,.  .^     .,-v.v-*..  ^..      Sr,    _    _^ 


A     TREATISE 
OF    HUMAN    ANATOMY 

KDITKD     BY 

P.   POIRIER  and  A.   CHARPY 

Profcssettr  ft' Anatomic  a  Pro/esseur  d' Anatomic  a 

la  Faciilte  dc  Paris,  la  Facultf  de  Mede- 

Chirurgicn  dcs  Hofiitaux        cine  a  Toulouse 


THE    LYMPHATICS 


THE    LYMPHATICS 

GENERAL    ANATOMY    OF    THE    LYMPHATICS    BY 

G.   DELAMERE 


SPECIAL    STUDY    OF    THE    LYMPHATICS 
IN     DIFFERENT     PARTS     OF     THE      BODY     BY 

P.   POIRIER  and  B.   CUNEO 

Professeur  d*  Anatomic  a  la  Faculte  dc  Professeur  figrege  a  la  Vacultfide 

Me'dedne  a  Paris,  Cbtrurgien  dcs  Hopltaux  Medcclne  dc  Paris 

AUTHORISED    ENGLISH    EDITION 

TRANSLATED     AND      EDITED      BY 

CECIL  H.  LEAF 

M.A.,  M.B.   (Cantafi.1,  F.A'.C.S.  (Eng.\  Assistant  Sutyeon  to 

the  Cancer  Hospital,  and  to  the  CorJon  Hosf-italfor 

Rectal  Diseases.   Late  Demonstrator  of 

Anatomy,  London  Hospital 


WITH    117    ILLUSTRATIONS    AND    DIAGRAMS 


RnU 

\    .  '--  n 


CHICAGO 
W.    T.    KEENER   AND    CO 

90    WABASH    AVENUE 
1904 


All  rights  reserved 


In  compliance  with  current  copyright  law, 

U.C.  Library  Bindery  produced  this  replacement  volume  on 

paper  that  meets  the  ANSI  Standard  Z39.48-1984  to  replace 

the  irreparably  deteriorated  original. 


1990 


TO    THE    MEMORY    OF 
PROFESSOR   SAPPEY 


Editor's   Preface 

THIS  work,  a  section  of  The  Treatise  of  Human  Anatomy,  edited  by 
P.  Poirier  and  A.  Charpy,  is  divided  into  two  parts.  The  first — 
on  the  General  Anatomy  of  the  Lymphatic  System — is  by  G. 
Delamere.  The  second — on  the  Special  Study  of  the  Lymphatics 
in  different  regions  of  the  body — is  by  P.  Poirier  and  B.  Cuneo. 
The  names  of  these  authors  are  sufficient  guarantee  of  the  care 
and  accuracy  bestowed  on  their  respective  subjects. 

From  a  practical  point  of  view,  a  thorough  knowledge  of  the 
histology  and  functions  of  the  lymph,  and  definite  ideas  as  to  the 
arrangement  and  distribution  of  the  lymphatic  vessels,  become 
more  and  more  essential  every  day.  In  both  these  subjects  it 
will  be  found  that  the  present  work  considerably  extends  our 
knowledge. 

Gerota's  method  of  injection,  which  was  advocated  by  Poirier 
in  1892,  has  been  freely  used  by  the  authors,  with  the  result  that 
our  knowledge  of  the  lymphatics  of  certain  regions  of  the  body, 
which  were  not  well  adapted  for  injections  by  mercury,  is  more 
complete  to-day  than  it  was  in  the  past. 

In  the  work  of  translation  I  have  endeavoured  as  far  as  possible 
to  reproduce  the  French,  but  where  there  was  any  possibility  of 
ambiguity  resulting  therefrom,  I  have  not  hesitated  to  give  a 
free  rendering. 

I  have  much  pleasure  in  acknowledging  my  indebtedness  to 
my  brother,  F.  Walton  Leaf,  for  kindly  overlooking  the  proof- 
sheets,  and  for  many  timely  and  valuable  suggestions. 

CECIL   H.    LEAF. 

WIMPOLE  STREET, 

August,  1903. 


VII 


The  Lymphatics 

FIRST  PART 

GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM 

Page 
GENERAL  CONSIDERATIONS       ........          3 

LYMPH            ...........  4 

LEUCOCYTES            .         .         ....         .          .          .          .  9 

I.  THE  WHITE  CORPUSCLE  IN  GENERAL                                        .  0 

II.  THE  DIFFERENT  LEUCOCYTKS  .          .                                       .  32 
THE  LYMPHATIC  VESSELS        ....                             .          .  5(i 

THE  LYMPHATIC  GLANDS         ..          .                    .  81 


SECOND  PART 

SPECIAL     STUDY     OF     THE     LYMPHATICS     OF     THE 

BODY 

CHAPTER  I.     LYMPHATICS  OF  THE  LOWER  LIMB    .       "."•';     111 

I.  GLANDULAR  GROUPS  OF  THE  LOWER  LIMB  .          .          .     112 

II.  LYMPHATIC  VESSELS       ,,  „  ,,  ...     120 

CHAPTER  II.     LYMPHATICS     OF     THE     PELVIS     AND 

ABDOMEN    .          ......          .          .          .  .      129 

T.  GLANDULAR  GROUPS  OF  THE  PELVIS  AND  ABDOMEN  .129 

1.  Ilco-pel vie  Glands     .          .          .          .          .          .  .129 

2.  Abdomino-aortic  Glands  .          .          .          .  .139 
II.  LYMPHATIC  VESSELS  OF  THE  PELVIS  AND  ABDOMEN   .  .      148 

1.  Lymphatics  of  the  Abdominal  Wall    .          .    '      .          .     148 

2.  „             .,  External  Genital  Organs  .  .      152 

3.  ,,              ,.  Internal  Genital  Organs  .  .      160 

4.  ,,              .,  Urinary  Passages           .  .  .175 

5.  ,,              .,  Sub-diaphragmatic  Portion  of  the 
Digestive  Tube  .          .          .          .          .  .  .      18G 

CHAPTER  III.     LYMPHATICS  OF  THE  THORAX  .          .          .  208 

I.  GLAND ULAH  GROUPS  OF  THE  THORAX    .  ...  208 

1.  Parietal  Glands        .          .          .          .  .          .          .  208 

2.  Visceral  212 


x  TABLE    OF    CONTENTS 

Page 
IT.  LYMPHATIC  VESSELS  OF  THE  THORAX        .          .          .          .215 

1.  Parietal  Lymphatic  Vessels         .          .  .  .  .215 

2.  Visceral  „  „ 228 

CHAPTER  IV.     LYMPHATICS  OF  THE  UPPER  LIMB  .          .          .233 

I.  LYMPHATIC  GLANDS  or  THE  UPPER  LIMB      .          .          .          .233 

II.  LYMPHATIC  VESSELS      ,,  ,,         ,,  .  •        .          .          .     240 

CHAPTER  V.     LYMPHATICS  OF  THE  HEAD  AND  NECK     .          .      247 

I.  GLANDULAR  GROUPS  OF  THE  HEAD  AND  NECK    .          .          .     247 

1.  Peri-cervical  Glandular  Circle  .....      247 

2.  Descending  Cervical  Chains       .          .          .  .  .256 

II.  LYMPHATIC  VESSELS  OF  THE  HEAD  AND  NECK     .          .          .203 

1.  Lymphatic  Vessels  of  the  Cranial  Region          .  .          .      263 

2.  „  „  „        Face  .      205 

3.  „  „  ,,       Fncio-Cervical    Portion     of 

the   Digestive  -Passages 209 

4.  Lymphatic    Vessels  of  the  Facio-Cervical   Portion  of 

the  Respiratory  Passages       .....      283 

CHAPTER  VI.     TERMINAL  COLLECTING  TRUNKS  OF  THE  LYMPHA- 
TIC SYSTEM  .          .          .          .          .          .     290 

I.  TERMINAL  COLLECTING  TRUNKS   OF  THE   SUPRA-DIAPHRAG- 

MATIC  PORTION  OF  THE   BODY        .....     290 

II.  THORACIC  DUCT  292 


Introduction 

EVER  since  the  commencement  of  my  works  on  anatomy  (1876)  I 
have  been  especially  attracted  towards  the  study  of  the  lymphatic 
system.  Admitted  into  the  private  laboratory  of  my  master, 
the  lamented  Professor  Sappey,  I  learnt  from  him  the  method  of 
injecting  by  mercury.  Under  the  direction  and  control  of  this 
kind  and  skilful  master,  I  have  studied  the  lymphatics  of  numerous 
organs,  and  I  have  been  fortunate  enough  to  be  able  to  fill  in  the 
details  of  former  works  and  supplement  them  on  many  points — 

"  Lymphatic  Vessels  of  the  Larynx  :  the  Praelaryngeal  Gland." 
Societe  Anatomique  et  Progres  Medical,  1887. 

"  Lymphatic  Vessels  of  the  Articulations."  Traite  (T Anatomic 
Humaine,  vol.  i.  p.  557. 

"Vessels  and  Lymphatic  Glands  of  the  Lower  Limb  and  of  the 
Inguinal  Region  "  ;  specimens  placed  in  the  Museum  of  the  Faculty. 

"  Lymphatics  of  the  Testicle  arid  of  the  Spermatic  Cord  "  ;  speci- 
mens prepared  for  the  meeting  of  Prosectors,  1883  ;  placed  in  the 
Museum  of  the  Faculty. 

"  Lymphatic  Vessels  of  the  Meninges,  and  of  the  Encephalon." 
Anatomic  Medico-Chirurgicale,  pp.  164-165,  1892. 

"  Lymphatics  of  the  Female  Generative  Organs  :  Uterus,  Vagina, 
Fallopian  Tube,  Ovary."  Societe  Anatomique  et  Pr ogres  Medical, 
1890. 

"Lymphatics  of  the  Tongue."  Traite  d'Anatomiehumaine,  t.  iv. 
p.  105,  1895,  and  Gazette  Hebdomadaire,  1902. 

"Lymphatic  Glands  of  the  Axilla."     Progres  Medical,  1888. 

Numerous  illustrations  accompany  the  various  articles,  of  which 
a  number  have  become  classical,  and  have  been  reproduced  in 
France  and  abroad. 

In    recent    years   a   method   of  injection  with   Prussian    blue, 


xii  INTRODUCTION 

called  "  Gerota's  process,"  having  been  applied  to  the  study  of  the 
lymphatic  vessels  and  glands,  I  asked  my  pupil,  colleague  and 
friend  Cuneo,  who  introduced  this  method  into  France,  to  teach 
me  the  technique,  the  use  of  which  I  had  advocated  since  1892 
(Anatomie-medico-chirurgicale,  pp.  164-165),  and  which  he  has 
applied  with  known  success  to  the  study  of  the  lymphatics  of  the 
stomach,  the  bladder,  the  rectum,  and  genital  organs.  Together  we 
have  again  undertaken  the  study  of  the  lymphatics  of  the  entire 
body,  as  much  with  the  object  of  perfecting  our  knowledge  on  the 
subject  as  for  adding  to  well-ascertained  facts. 

As  I  felt  incompetent  to  adequately  deal  with  the  histology  of 
the  lymphatic  vessels  and  glands  and  of  the  lymph,  which  is  so 
important  a  matter,  I  entrusted  this  part  of  the  work  to  my 
devoted  pupil  Delamere,  who  has  personally  undertaken  these 
researches  in  the  laboratory  and  under  the  guidance  of  Professor 
Mathias  Duval. 

It  follows  therefore  that  this  portion  of  the  treatise  of  Human 
Anatomy  (the  last  but  one)  is,  like  the  preceding  ones,  not  simply 
a  general  review,  a  work  of  compilation,  but  is  a  record  of  opinions 
which  have  been  formed  as  a  result  of  personal  researches.  It 
shows  the  state  of  the  science  of  to-day  and  indicates  the  lines  on 
which  the  work  must  be  conducted  in  the  future. 


General   Anatomy   of  the   Lymphatic   System 


BY 

G.  DELAMERE. 


FIRST  PART. 

General  Anatomy  of  the    Lymphatic  System 

BY 

GABRIEL  DELAMERE. 

THE  Lymphatic  System  is  made  up  of  vessels  which,  after  travers- 
ing the  glands,  bring  the  lymph  into  the  venous  system.  The 
capillaries  of  origin  have  closed  extremities  which  never  penetrate 
beyond  the  epithelial  linings  ;  by 
their  anastomoses  they  form  primary 
networks,  from  which  commence  the 
first  collecting  trunks,  which  divide 
again  into  capillaries  on  traversing 
the  gland.  Passing  out  of  the  gland 
the  efferent  vessels  join,  and  form  the 
large  terminal  collecting  trunks,  tri- 
butaries of  the  vena  cava  superior. 

In  man,  the  terminal  collecting 
trunks  are  usually  two  in  number  : 
the  thoracic  duct  and  the  right  lym- 
phatic duct. 

The  interposition  of  glands  daring 
the  passage  of  the  lymph  gives  the 
lymphatic  system  an  entirely  pecu- 
liar character  ;  in  fact,  it  appears  as 
though  formed  of  a  series  of  portal 
systems  superposed. 

The  study  of  the  lymph  and  the  leucocytes,  being  necessary  to 
the  thorough  comprehension  of  this  system  and  that  of  the  glands, 
we  will  study — 

1.  The  lymph. 

2.  The  leucocytes. 

3.  The  lymphatic  vessels. 

4.  The  glands. 

B* 


FIG.  1. — General  scheme  of  tho 
lymphatic  system  1.  Origin  of 
capillaries  close  under  the  epithe- 
lium ;  2.  Networks  which  give  origin 
to  the  collecting  trunks,  which 
divide  into  capillaries  in  the  gland  ; 
3.  Larger  but  less  numerous  efferent 
trunks  which  divert  the  lymph  into 
the  venous  blood  (portal  lymphatic 
system  of  the  gland). 


4  THE    LYMPHATICS 

The  lymph  is  generally  considered  a  tissue,  of  which  the  cells — 
the  leucocytes — are  placed  in  a  fundamental  liquid,  the  plasma. 
We  consider,  however,  that  the  essential  part  of  the  lymph  is  the 
plasma ;  and  the  typical  elements  which  it  contains,  and  of  which 
the  most  essential  are  the  leucocytes,  are  only  casual  guests. 
Contrary  to  custom,  we  shall  devote  a  separate  chapter  to  their 
consideration. 

The  plasma,  moreover,  or,  if  one  prefers  to  call  it  so,  the  lymph — 
for  these  are  in  our  opinion  two  synonymous  terms — ought  not  to 
be  considered  as  a  simple  product  of  filtration,  but  rather  as  a 
secretion,  the  genuine  result  of  cellular  activity. 

Claude  Bernard,  having  shown  that  soluble  salts  such  as  iodide  of  potas- 
sium or  prussiate  of  potash,  injected  into  the  blood,  pass  immediately  into 
the  lymph,  and  Noll  and  Ludwig  having  demonstrated  the  influence  of  blood 
pressure  on  the  lymphatic  flow,  it  has  become  customary  to  speak  of  the 
lymphatic  plasma  as  being  the  result  of  capillary  filtration  from  the  serum 
of  the  blood. 

In  spite  of  this,  it  is  onh'  possible  for  us  to  regard  it  as  a  selective  filtration 
process,  seeing  that  Cheauveau  found  much  less  glucose  in  the  lymph  plasma 
than  in  the  bloocl  plasma.  It  should  be  added  that  for  some  time  other  authors 
have  suspected  that  the  lymph  was  not  a  simple  product  of  filtration  ;  thus, 
according  to  Ch.  Robin,  it  is  formed  not  only  from  substances  derived  from 
the  blood  plasma,  but  very  probably  also  from  the  breaking  up  of  anatomical 
elements.  Longet  holds  that  it  is  a  sort  of  chyle  which  is  formed  at  the 
expense  of  the  actual  substance  of  the  animal.  But  of  late  years  one  is 
compelled  to  strenuously  oppose  the  idea,  always  a  classical  one,  of  the  lymph 
being  a  mechanical  product  of  filtration  from  the  blood.  It  was  Heidenhain 
originally,  who  seeing  the  lymph  form  and  circulate  one  or  two  hours  after 
a  subdiaphragmatic  ligature  of  the  aorta,  concluded  that  the  lymph  was 
not  a  product  of  filtration  but  a  product  of  enclothelial  secretion.  The 
same  physiologist  also  remarks  that  certain  substances  act  as  lymphagogues 
as  long  as  the  blood  pressure  remains  normal  or  a  little  under.  The  action 
of  these  bodies  can  only  be  explained  on  the  supposition  that  they  call  upon 
the  fixed  elementary  tissues  for  a  supply  of  lymph.  Starling  contests  these 
deductions  :  he  thinks  that  in  Heidcnhain's  experiment  the  lymph  comes 
from  the  liver  and  that  the  subdiaphragmatic  ligature  of  the  aorta  does  not 
alter  the  pressure  in  the  hepatic  capillaries.  According  to  him,  the  lympha- 
gogues  paralyze  the  muscular  walls  of  the  vascular  system,  and  especially, 
by  altering  the  endothelium,  increase  its  permeability. 

In  order  to  verify  Heidenhain's  views,  and  to  rebut  the  objections  raised 
by  Starling,  Hamburger  studied  the  behaviour  of  lymph  in  the  neck  of 
a  horse  whose  head  was  rendered  immobile,  but  whose  body  and  limbs  were 
allowed  to  move.  Under  these  conditions,  he  has  seen  the  quantity  of  lymph 
become  tripled  and  quadrupled  in  spite  of  the  diminution  of  pressure  in  the 
carotids  and  jugulars.  Finalty,  by  the  haemolytic  method  he  has  found  that 
the  lymph  possessed  greater  osmotic  powers  than  the  serum  in  the  jugular. 
In  the  same  way,  by  means  of  the  cryoscope,  Leathes,  Fano  and  Bottazi, 
have  shown  that  the  coagulation  point  (A)  of  lymph  is  always  higher  (further 
removed  from  0°)  than  that  of  the  blood. 


GENERAL    ANATOMY  OF  THE  LYMPHATIC  SYSTEM     5 

A  (lymph)  A  (serum)  (Leathes). 

-  0°  620       -  0°  610. 

-  0°  630       -  0°  625. 

-  0°  625        -  0°  617  (Fano  and  Bottazi). 

According  to  Fano  and  Bottazi,  injections  of  phosphorus,  which  destroy 
the  endothelial  wall,  produce  no  effect  upon  the  concentration  of  the  blood, 
but  diminish  the  concentration  of  lymph  in  the  thoracic  duct  (before  in- 
jection, A-0°63;  after  injection,  A-0°58). 

Tscherewkow  positively  states  that,  though  venaesection  diminishes  the 
amount  of  solid  elements  in  the  blood  serum  to  a  marked  degree,  the  lymph 
is  unaffected. 

Aslier  and  Barbera  find  that  lymph  increases  in  the  same  proportions  as 
the  nitrogen  in  the  urine  ;  its  toxicity  is  greater  than  that  of  blood.  It  is 
the  result  neither  of  a  filtration  (the  classical  theory),  nor  of  an  endothelial 
secretion  (theory  of  Heidenhain)  :  it  owes  its  origin  to  the  vital  functions 
of  cells. 

Moussu  does  not  regard  the  lymph  as  being  secreted  by  the  endothelium 
of  the  blood  capillaries.  Its  production  is  aided  by  the  blood  pressure  : 
above  all  it  results  from  the  functional  activity  of  the  tissues.  In  fact,  both 
chemistry  and  the  cryoscope,  demonstrate  the  fact  that  lymph  is  different 
from  blood  ;  physiology  makes  us  regard  it  not  so  much  as  a  product  of 
filtration  as  of  a  vital  elaboration  from  cells.  Containing  the  residual  pro- 
ducts of  cellular  life,  we  regard  it  as  a  kind  of  fluid  excretion. 

It  would  seem  at  first  sight  peculiar  that  such  a  fluid,  instead  of  being 
eliminated  externally,  should  be  poured  into  the  venous  blood,  and  that  it 
should  afterwards  pass  again  into  the  organs  with  the  arterial  blood.  But 
i*  not  this  fluid  at  first  modified  in  the  lymphatic  glands,  and  again  perhaps 
in  the  pulmonary  endothelium  ?  Certain  experiments  of  Brown-Sequard 
tend  to  prove  the  pathogenic  properties  of  expired  air,  and  it  may  be  that 
their  expiration  is  the  result  of  the  excretion  of  certain  toxic  matters  from 
the  lungs.  Moreover,  though  the  physiologists  (Starling,  Asher,  Moussu),  do 
not  admit  the  existence  of  an  endothelial  secretion  of  blood  capillaries,  which 
is  Heidenhain's  view,  Ranvier  has  shown  the  histological  existence  of  an  en- 
dothelial lymphatic  secretion  :  the  lymph  is  not  only  a  liquid  excretion,  it 
is  even  more,  a  product  of  secretion.  Therefore  it  is  not  surprising  that,  like 
the  internal  secretions  of  the  thyroid  gland  and  the  suprarenals,  it  is  poured 
into  the  blood. 

The  lymph  contains  leucocytes  also,  which  are,  so  to  speak,  its  casual  guests. 
It  is  supplied  with  little  or  no  oxygen  in  the  trunks,  and  therefore  affords 
a  most  unsuitable  medium  for  their  development.  Later  on  we  will  speak 
of  the  morphological  varieties  which  are  met  with  ;  for  the  present,  however, 
we  will  confine  ourselves  to  the  study  of  their  number.  The  number  is  much 
greater  at  the  centre  than  at  the  periphery  of  the  system.  Formerly,  Frey 
had  remarked  that  the  commencing  chyliferous  vessels  contained  few  or  m> 
cells  at  all.  Recently  Renaut  has  noted  the  absence  of  leucocytes  in  the 
capillaries  of  origin  of  the  loose  connective  tissue  of  the  marmot.  All  authors 
find  that  the  number  of  leucocytes  are  considerably  increased  after  their  pas- 
sage through  the  gland.  Judging  from  the  somewhat  numerous  ideas  ex- 
pressed in  the  older  writings,  the  number  of  leucocytes  in  the  lymph  is  very 
variable,  not  only  in  different  animals,  but  also  in  different  animals  of  the 
same  species  :  thus  Malassez  counts  only  180  in  a  cubic  millimetre  of  frog's 
lymph,  Ranvier  counts  11,300  in  the  same  quantity  of  rabbit's  lymph,  4,800- 
and  7,500  in  the  lymph  of  the  dog,  and  8,200  in  that  of  man. 


6  THE    LYMPHATICS 

Again  one  finds  some  red  blood  corpuscles  in  the  lymph,  but  always  in 
small  quantities.  They  are,  however,  sometimes  so  numerous  as  to  impart 
a  rosy  tint :  this  rose  colouration  was  specially  observed  in  the  lymph 
coming  from  the  spleen,  or  from  lymphatic  glands  (Hewson,  Gulliver,  Lane 
and  Ancel,  Simon,  Reuss  and  Emmert).  It  increases  in  the  lymphatic 
Aressels  which  have  been  blocked  by  a  ligature  (Eisner,  Retterer),  and  when 
the  blood  pressure  rises  (Strieker,  Hering,  Laulanie).  Finally,  it  would 
appear  as  though  the  lymph  becomes  reddest  in  starving  animals  (Collard 
de  Martigny,  Nasse).  In  contradistinction  to  these  last-mentioned  authors, 
I  have  noted  the  perfect  whiteness  of  both  chyle  and  lymph  in  a  rabbit 
and  a  dog  which  have  died  from  starvation.  Similarly,  I  have  bled  some 
animals  without  being  able  to  observe  the  slightest  red  colour  in  their 
lymph — an  observation  already  made  by  Hayem. 

The  presence  of  red  blood  cells  is  not  perhaps  absolutely  constant,  since 
Kolliker  has  not  found  them  in  human  chyle,  but  unquestionably  they 
are  frequently  present.  One  cannot  agree  with  Krause,  who  asserts  that 
lymph  collected  without  accidental  mixing  with  blood,  is  always  destitute 
of  red  blood  corpuscles.  It  seems  that  the  presence  of  some  of  them  may 
be  explained  by  the  reflux  of  venous  blood  into  the  thoracic  duct  (Colin). 
In  the  case  of  hyperdis tension,  others  come  from  blood  vessels,  either  owing 
to  rupture,  or  by  diapedesis.  However,  it  is  not  probable  that  such  is 
their  sole  origin,  and  without  affirming  as  the  old  authors  have  done,  that 
the  red  blood  corpuscles  are  always  derived  from  the  white  corpuscles, 
we  may  ask  if  some  of  them  do  not  come  from  lymphatic  glands.  We  will 
study  this  question  when  dealing  with  the  functions  of  these  organs. 

Before  undertaking  the  chemical  study  of  the  plasma  of  the  lymph,  it 
is  advisable  to  recall  its  histological  characters.  On  the  one  hand,  Renaut 
considers  that  this  plasma  contains  no  albuminoid  matter  in  the  capillaries 
of  origin.  On  the  other  hand,  Ranvier  has  observed  in  the  trunks,  granules 
of  a  hyaline  substance,  myeloid  in  nature,  which  are  stained  yellow  by 
picrocarmin ;  these  granules  are  manufactured  by  the  endothelium. 
Retterer  also  found  granules  in  the  lymphatic  plasma.  I  have  observed 
the  same  thing  in  the  contents  of  the  lymphatic  capillaries  of  the  glands, 
and  of  that  of  the  thoracic  duct.  These  granules  are  more  rare  in  the  blood 
vessels,  with  the  exception  of  those  in  the  liver. 

The  origin  of  these  granular  coagula  seems  complex  :  the  granules  are 
apparently  derived  as  much  from  the  endothelium  as  from  the  protoplasm 
of  the  white  blood  corpuscles.  Admitting  that  secretion  takes  place  to  a  con- 
siderable extent  within  the  intraglandular  passages,  it  is  possible  that  the 
formation  of  these  granules  is  also  one  of  the  products  of  the  secretion  of  the 
lymphatic  gland. 

All  that  we  know  of  the  lymph,  its  origin,  and  the  alterations  it  most 
probably  undergoes  after  traversing  the  gland,  lead  us  to  think  that  it  pos- 
sesses a  very  variable  chemical  composition,  which  depends  not  only  upon 
the  condition  of  the  animal,  but  also  upon  the  particular  vessel  from  which 
the  lymph  is  drawn.  This  explains  the  discrepancies  which  have  been  ob- 
served in  the  different  analyses  published  up  to  the  present  time,  notably 
by  Schmidt,  Gubler  and  Quevenne,  Hensen  and  Dahnhardt ;  it  also  explains 
the  difference  which,  it  is  now  recognized,  exists  between  the  peripheral 
lymph  and  the  mesenteric  lymph  or  chyle.  In  reality,  the  difference  simply 
amounts  to  this  :  that  the  chyle  is  loaded  with  fat  derived  from  the  lacteals 
of  the  intestine. 

The  lymph  is  a  slightly  viscous  liquid,  with  no  colour,  or  with  a  colour 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM   7 

varying  from  a  slight  lemon  or  hardly  recognizable  opal,  to  a  yellow  tint — 
that  is,  before  its  passage  through  the  gland.  The  moment  digestion  com- 
mences it  becomes  milky.  In  the  thoracic  duct  and  in  the  efferent  vessels 
of  the  spleen,  we  have  seen  that  sometimes  it  is  of  a  faint  rosy  tint. 

It  is  as  a  rule  inodorous  :  but  some  observers  detect  a  faint  odour,  which 
varies  in  different  kinds  of  animal.  Others  maintain  that  when  cold,  the 
chyle  smells  like  spermatic  fluid,  and  when  heated,  like  fat.  It  is  faintly 
alkaline  to  the  taste.  Its  specific  gravity  varies  between  1,015  and  1,045  ; 
that  of  chyle  between  1,012  and  1,022.  It  is  less  alkaline  than  blood-lymph, 
requiring  0'35  gr.  lactic  acid  to  neutralize  100  grs.,  whereas  blood,  requires 
0'50  gr.  to  neutralize  the  same  quantity. 

According  to  Krause,  the  total  quantity  of  lymph  equals  one-third  the 
weight  of  the  body  ;  according  to  Ludwig  and  Majendie,  one  fourth  ;  Bidder 
says  that  in  the  cat  and  dog  it  is  equivalent  (approximately)  to  from  \  to  £  of 
the  weight.  In  the  case  of  the  horse,  Schmidt  has  obtained  in  twenty-four 
hours  a  quantity  of  lymph  equal  to  the  total  quantity  of  blood.  More 
recently  Moussu  has  obtained  in  ten  minutes,  from  different  horses  in  a  state 
of  rest,  quantities  varying  between  0'60  gr.  and  6'50  gr. — on  an  average  a 
little  more  than  two  grammes.  'In  the  ox  he  has  also  obtained  in  the  same 
time  quantities  varying  from  2-26  gr.  In  an  ox  of  average  weight  the 
amount  is  a  little  more  than  10  gr. 

By  making  a  fistula  in  the  thoracic  duct,  Colin  has  obtained  95  kgs.  286 
grammes  in  twenty-four  hours.  In  the  dog,  Lesser  has  obtained  300  cubic 
centimetres  in  four  hours  ;  in  man,  5  litres  and  a  half  have  been  collected  in 
the  same  time.  The  quantity  depends,  we  know,  not  only  upon  mechanical 
influences  such  as  pressure,  etc.,  but  especially  upon  cellular  activity  in  all 
its  conditions  ;  thus,  Moussu  has  collected  5,  10,  and  even  20  times  more 
lymph  from  an  animal  in  a  state  of  activity,  than  from  the  same  animal  in  a 
state  of  rest. 

Lymph  increases  fairly  quickly  under  the  influence  of  pilocarpine,  less 
quickly  under  that  of  ergotine  ;  it  increases  also  after  the  injection  of  certain 
toxins  (Charrin,  Moussu) ;  after  a  hypotensive  dose  of  toxin,  viz.  diphtheria 
toxin,  and  also  after  a  hypertensive  dose  of  toxin,  such  as  tuberculin.  Though 
Beard  and  Wilcox,  and  Retterer,  firmly  believe  they  have  seen  the  lymph 
increase  after  bleeding,  Moussu,  on  the  other  hand,  has  stated  that  in  the  horse, 
bleeding  to  the  extent  of  4  litres  has  led  to  a  marked  diminution  of  this  fluid. 
Ranvier  has  seen  the  lymph  diminish  considerably  in  frogs  which  have  been 
placed  in  a  vacuum,  or  kept  in  a  dry  place.  In  the  case  of  the  curarized 
frog,  the  lymph  accumulates  in  the  retrolingual  space  (Ranvier,  Tarchanoff). 

Regarding  the  numerous  lymphagogues  we  ought,  as  Heidenhain  suggests, 
to  classify  them,  and  place  in  the  first  class  such  as  are  of  an  albuminoid 
nature,  or  of  animal  origin,  such  as  the  muscle  extract  of  the  crayfish,  head 
and  body  of  leeches,  bodies  of  aiiodons,  the  intestine  and  liver  of  the  dog,  and 
the  peptones.  In  the  second  class,  crystalloids :  the  sugar,  salts,  and  urea,  should 
be  included.  Outside  the  vessels  lymph  coagulates  more  slowly  than  blood, 
taking  from  five  to  twenty  minutes.  1,000  parts  of  lymph  yield  44*8  parts 
of  clot  (Schmidt)  ;  the  same  quantity  of  chyle  produces  only  32' 6  of  clot. 
The  clot  is  soft,  somewhat  white,  slightly  retractile.  The  serum  is  colourless 
and  transparent. 

Coagulation  yields  considerably  less  fibrin  than  that  given  by  the  same 
quantity  of  blood.  In  1,000  parts  of  lymph  taken  from  the  inguinal  glands 
of  the  bull  and  cow,  Schmidt  finds  1*2  gr.,  2  gr.,  and  2'2  gr.  of  fibrin. 
In  the  same  quantity  of  human  lymph,  Hensen  and  Dahnhardt  find  1'07  gr. 


8  THE    LYMPHATICS 

According  to  others,  the  amount  varies  between  0*4  gr.  and  0'8  gr.  The 
tendency  to  fibrin  formation  and  coagulation  becomes  more  rapid,  after  the 
passage  of  lymph  through  the  glands  (Chaussier,  Albertoni,  Hofmeister),  and 
after  the  action  of  curare.  On  the  contrary,  coagulation  takes  place  more 
slowly  after  the  action  of  certain  toxins  (Charrin).  Chemically,  lymph  is 
an  aqueous  liquid  which  contains  albuminoid  matters  (globulin,  serin,  fibrin), 
fat,  sugar,  urea,  salines  and  gas.  The  proportion  of  water  is  here  much 
greater  than  it  is  in  blood  (from  929' 7  to  987 '7  in  1,000  parts)  ;  the  water 
diminishes  after  the  passage  of  lymph  from  the  gland.  In  chyle  there  is 
usually  less  water  than  there  is  in  lymph  at  the  periphery  (from  904*8  to 
964-4). 

On  the  contrary,  the  richness  in  albuminoid  matter  is  less  than  that  of 
blood.  It  ranges  from  3' 37  gr.  to  52' 9  gr.  In  the  chyle  it  ranges  from 
22-25  gr.  to  70- 1  gr.  Some  of  the  proteid  substances  of  chyle  are  precipitated 
by  acetic  acid,  others  by  alcohol  ;  their  weight  may  be  increased  from  30 
to  70  in  every  1,000  during  digestion.  The  albuminoids  also  increase  in 
starvation. 

Fats  are  met  with  in  variable  proportions — from  a  trace  up  to  30  for  every 
1,000;  in  the  chyle,  after  a  repast,  up  to  65  for  every  1,000  parts:  apart  con- 
sists of  neutral  glycerides  peculiar  to  the  special  animal  under  consideration, 
the  other,  of  soaps  of  the  fatty  acid  series,  of  lecithin  (A.  Gautier)  ;  in  the 
chyle,  cholesterine  and  amins  are  found  (Dobroslavine).  After  passing  from 
the  gland,  less  fat  is  usually  found. 

The  proportion  of  sugar  is  low,  much  lower  than  that  of  the  blood  (Chau- 
veau).  Wurtz  only  finds  traces  of  it.  Poiseulle  and  Lefort  have  obtained 
0'016  gr.  and  0'0098  gr.  in  1,000  parts  of  lymph  taken  from  the  dog  or  cow. 
In  1,000  parts  of  human  lymph  Gubler  and  Quevenne  have  found  0*5  gr. 

There  is  O'l  gr.  of  glycogen  for  every  1,000  parts. 

100  parts  of  lymph  contain  from  0'012  to  0*021  part  of  urea. 

Saline  matters  (chloride  of  sodium,  phosphates,  sulphates  and  alkaline 
carbonates)  are  found  in  nearly  the  same  proportions  as  in  blood — from 
7  to  15  gr.  ;  on  an  average  8  gr.  per  litre  in  human  lymph.  There  is  some 
iron  in  lymph  and  chyle. 

According  to  Hammersten,  100  gr.  of  lymph  contain  42-28  gr.  of  gas  in  the 
following  proportions  :  Carbonic  acid  gas,  40*32  gr.  (from  28—40*32)  ;  nitrogen, 
1-63  gr.  ;  oxygen,  0'43  gr.  (from  0  to  0'43). 

In  the  chyle,  Hensen  has  precipitated  a  diastatic  ferment  by  alcohol  ; 
lymph  also  contains  an  amylase.  Dastre  has  concluded  that  glycogen 
only  exists  in  the  plasma  in  the  white  corpuscles. 

Floresco  has  affirmed  that  after  an  injection  of  propep tones,  or  of  extract 
of  leeches'  heads,  the  incoagulable  lymph  of  the  thoracic  duct  causes  coagu- 
lation of  the  casein  of  milk.  It  contains  some  rennet,  which  diminishes 
during  fasting.  The  lipase  exists  only  in  very  small  quantities  (Duclaux). 

Lymph  cannot  be  a  reducing  agent,  seeing  that  Gautier  (1881)  and 
Ehrlich  (1890)  having  injected  coloured  substances  such  as  indigo,  alizarin 
and  cerulein  blues,  into  a  living  animal,  substances  which  become  dis- 
coloured while  absorbing  hydrogen,  have  stated  that  it  has  a  tint  similar  to 
blood  and  some  of  the  other  tissues. 

BIBLIOGBAPHY. — Magendie.  Precis  elementaire  de  physiologic,  1825,  II. — 
Noll.  Zeitschrift  /.  ration.  Medicin,  1850,  IX. — Cl.  Bernard.  Lemons  sur  les 
anesthetiques  et  sur  I 'asphyxie,  1875. — Lesser.  Eine  Methode  um  grosse 
Lymphmengen  vom  lebenden  Hunde  zu  bekommen.  Arbeiten  aus  der  phys. 
Anstalt  zu  Leipzig,  mitgetheilt  durch  Ludwig,  1872. — Hammarsten.  Ueber 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM  9 

die  Gase  der  Hundelymphe.  Arbeiten  aus  der  phys.  Anstalt  zu  Leipzig, 
1872. — Robin.  Lecons  sur  les  humeurs,  1874. — Frey.  Eel.  fran£.,  1877. — 
Albertoni.  Ueber  die  Peptone.  Centralblatt  fur  die  med.  Wiss.,  1880,  no.  32. 
— Hofmeister.  U.  das  Schicksal  des  Peptons  im  Blut.  Zeit.  f.  phys.  Chemie, 
V. — Tarchanoff.  Do  1' influence  du  curare  sur  la  quantite  de  la  lymphe 
et  1' emigration  cles  globules  blancs  du  sang.  Arch.  Physiologie,  1785. — 
Krause.  Zur  Physiologie  der  Lymphe.  Zeitschrift  f.  rat.  Medicin,  1885,  \71T. 
— Colin,  Phys.  compares  des  animaux  domestiques,  1888,  II. — Heidenhain. 
Verusche  u.  Fragen  zur  Lehre  von  des  Lymphbildung.  Pfliigcr's  Archiv, 
1 80 1,XLIX.— Hamburger.  Zeit.  f.  Biol.,  1894.— Charrin.  C.  7?.  Soc.  Biol., 
1800. — Leathes.  Journ.  of  Phys.,  1806. — Tscherewkow.  Archiv.  f.  die  gesam. 
Phys.,  LXIT. — Fano  et  Bottazi.  Arch.  Hal.  biol.,  1896,  XXVI. — A.  Gautier. 
Lemons  de  chimie  biol.  ct  path.,  1807. — Asher  et  Barbera.  Untersuchungen 
iiber  die  Eigenschaften  u.  die  Enstehung  der  Lymphe.  Zeitschr.  f.  BioL, 
1808,  XXXVT-XXXVIL— Duclaux.  Traite  dc  Microbiologic,  1800,  II.— 
Moussu.  Recherches  sur  1'origine  de  la  lymphe  de  la  circulation  lymphatique 
peripherique.  Journal  de  V anatomic  ct  de -la  physiologic,  1001,  nos.  4-5. — 
Ranvier.  Traite  d'Histologie  pathologique,  1001. — Retterer.  Journal  de 
r Anatomic  ct  dc  la  Physiologie,  1001,  no.  6. 

LEUCOCYTES 

Under  the  generic  term  leucocytes,  or  white  blood  corpuscles, 
are  included  a  series  of  cells  which  are  met  with  in  the  blood,  the 
lymph,  and  connective  tissue  spaces.  Ranvier  has  objected  to 
this  term  (\evxos— white  ;  KVTOS— cell),  which  he  says  only 
causes  confusion  by  leaving  one  to  suppose  that  the  white  cor- 
puscles are  utricular  bodies  :  which  is  not  correct ;  others  object  to 
the  term  white  blood  corpuscle,  observing  that  these  bodies, 
colourless  though  they  maybe,  or  containing  yellow,  orange  or  black 
particles,  are  never  white.  Whilst  entirely  recognizing  the  justness 
of  these  remarks,  we  will  retain  these  terms,  which  have  been 
sanctioned  by  use,  as  we  cannot  replace  them  by  such  terms  as 
M  migratory  "  or  "  amoebic  "  cells.  The  amoebic  movement  is  not 
a  feature  which  is  peculiar  to  leucocytes  only ;  it  is  probably 
common  to  all  cells  at  all  times. 

We  will  study  :— 

1.  The  structure,  the  physical,  chemical   and  biological  proper- 
ties, the  evolution  (degeneration  and  death)  of  the  leucocyte. 

2.  The  different  kinds  of  leucocytes. 

1.     THE  WHITE  CORPUSCLE  IN  GENERAL. 

Structure.— We  will  consider  (1)  the  nucleus;  (2)  the  proto- 
plasm . 

NUCLEUS.— In  the  different  kinds  of  leucocytes,  the  nucleus  varies 
considerably,  not  only  in  its  size,  shape  and  situation,  but  also 


10  THE    LYMPHATICS 

in  the  arrangement  and  disposition  of  its  chromatin.  Large  or 
small,  placed  in  the  centre  or  away  from  it,  it  is  rounded,  oval, 
elongated  or  polymorphous,  and  sometimes  actually  multiple.  The 
polymorphism  of  these  nuclei  has  actively  engaged  the  attention  of 
c}^tologists  and  given  rise  to  many  theories  to  account  for  it. 

Even  if  we  admit  that  by  being  split  up  and  by  a  degenerative 
vacuolization,  leucocytes  can  present  multiple  perforated  nuclei, 
Flemming,  Heidenhain  and  Vander  Stricht,  have  proved  that  the 
polymorphism  is  not,  as  Ziegler  and  Schultze  believed,  a  sign  of 
degeneration,  or  even  of  age.  For  even  if  we  support  this  latter 
theory  by  supposing  that  the  nuclei  of  certain  epithelial  cells, 
which  are  rounded  in  young  animals,  become  irregular  and  twisted 
as  they  get  older,  we  must  also  admit  that  the  mere  fact  of  leucoc}Ttes 
possessing  amoeboid  properties,  and  being  able  to  act  as  phagocytes 
to  nuclei,  does  not  fit  in  well  with  the  theory  that  such  cells  are 
old  or  are  about  to  die.  We  shall,  when  studying  amoebic  move- 
ments, meet  with  direct  and  indirect  division  of  leucocytes,  what- 
ever the  generic  bearings  may  be  which  appear  to  exist  between 
these  phenomena  and  the  irregularity  of  the  nucleus.  These 
phenomena  apparently  are  not  able  to  explain  all  cases  of  poly- 
morphic nuclei.  It  is  interesting  to  compare  the  budding  nucleus 
of  leucocytes — the  unicellular  glands  (Ranvier,  Lowit)  to  the  ramified 
nucleus  of  the  immobile  glandular  cells  of  certain  Invertebrates 
(forms  observed  by  Mayer,  Heider,  Korschett,  Klaatsch,  Mont- 
gomery). It  is  worth  remarking  that  these  modifications  of  the 
nucleus  are  temporary,  and  probably  coincide  with'  the  secretory 
activity  of  the  cell ;  perhaps  the  polymorphism,  that  is  to  say,  the 
increase  of  the  nuclear  surface  of  certain  leucocytes,  bears  some 
re'ation  to  their  secretory  activity. 

Sometimes  the  chromatin  is  seen  as  a  network  of  more  or  less 
close  spaces,  sometimes  as  rounded  granules  (pseudo-nucleoli)  : 
these  latter  are  as  a  rule  more  or  less  central,  bound  or  not  to  other 
peripheral  granules  which  adhere  to  the  nuclear  membrane. 

In  the  leucocytes  of  the  salamander  fixed  by  sublimate,  M. 
Heidenhain  has  pointed  out  the  existence  of  a  coarse  chromatin 
network,  intimately  bound  up  with  a  much  more  delicate  network, 
formed  by  filaments  of  linin  ;  in  the  meshes  of  which  he  has  found 
albuminoid  granules,  which  are  well  coloured  with  acid  fuchsin. 
He  calls  this  substance  lanthin.  Henneguy  thinks  that  it  is  an 
albuminous  fluid  which  has  been  precipitated  by  the  sublimate  ; 
perhaps  this  fluid  corresponds  to  paralinin. 


GENERAL    ANATOMY  OF  THE  LYMPHATIC  SYSTEM       11 

Lowit,  while  studying  the  leucocytes  of  the  crayfish  with  the 
reagents  of  Schwarze  and  Zacharias,  found  that  their  nuclei  con- 
tained much  pyrenin.  Such,  he  thought,  ought  to  divide  directly. 
We  shall  see  later  on,  that  leucocytes  frequently  reproduce  them- 
selves by  karyokinesis. 

Hayem,  Ehrlich,  and  Lazarus  note  the  almost  constant  presence 
of  one  or  two  nucleoli  in  small  leucocytes  (lymphocytes),  without 
stating  definitely  if  they  are  made  up  of  pyrenosomes  or  of  pseudo- 
chromatin  nucleoli. 

In  certain  leucocytes  (myelocytes,  neutrophiles)  Levaditi  has 
coloured,  without  previous  fixing  with  the  brilliant  Kresyl  blue, 
forms  which  he  considers  resemble  nucleoli  ? 

PROTOPLASM. — We  will  study  (1)  its  composition  ;  (2)  its  different 
forms,  such  as  centrosomes  and  spheres  of  attraction  ;  (3)  its 
contents — absorbed  or  manufactured  by  the  cell. 

Composition.  —  Sometimes  simply  an  almost  imperceptible 
stratum,  sometimes  well  developed,  it  would  appear  that  the 
protoplasm  of  the  white  blood  corpuscles  has  the  power  of  reacting 
in  many  different  ways  to  stains  ;  at  times  it  is  neutral,  and  at 
others  acidophile  or  basophile.  Sometimes  almost  homogeneous, 
it  almost  always  has,  according  to  Flemming,  Heidenhain,  Schoefer, 
Arnold  and  Klemciewicz,  a  reticular  or  filamentous  structure.  In 
the  meshes  of  the  network  one  finds  spaces  filled  with  a  homo- 
geneous and  liquid  substance  ;  the  vacuoles  are  more  or  less 
abundant,  according  to  the  cells  considered. 

Schoefer  has  stated  that  the  leucocytes,  which  have  been  fixed 
on  a  slide  by  the  rapid  action  of  a  jet  of  steam,  present  a  reticular 
structure  in  the  centre,  whereas  the  pseudopods  remain  clear ; 
he  therefore  concludes  that  the  latter  are  simply  hyaloplasmic 
expansions  ;  Henneguy  likewise,  has  found  a  structure  purely 
vacuolar  in  the  central  part  of  the  leucocytes  of  earthworms,  in 
which  the  pseudopods  are  homogeneous.  Arnold,  after  macera- 
tion in  a  solution  of  iodo-iodide.  has  seen  corpuscles  which  are 
sometimes  rounded,  but  which  are  more  often  elongated  in  the  form 
of  little  rods  (plasmosomes).  These  plasmosomes  show  filiform 
prolongations,  which  unite  in  a  thousand  ways  so  as  to  produce  a 
filamentous,  reticular  or  spongy  appearance  ;  they  traverse  spaces 
filled  with  a  hyaline  paraplasm. 

Klemciewicz  observes  a  filamentous  structure  composed  of 
vacuoles  in  the  centre  and  an  ectoplasm  at  the  periphery  :  it  is 
perhaps  due  to  this  ectoplasm  that  the  cellular  juice,  in  spite  of 


12  THE    LYMPHATICS 

the  large  amount  of  water  it  contains,  does  not  continually  mix  with 
this  surrounding  liquid  :  at  all  events,  this  structure  enables  us  to 
understand  the  frequency  and  ease  with  which  changes  can  take 
place  between  the  cellular  contents  and  the  surrounding  medium. 
Centrosomes,  ami  Spheres  of  Attraction. — The  centrosomes  of 
leucocytes  have  been  studied  by  Flemming,  Hansemann,  M.  Hei- 
denhain,  and  Henneguy. 

Hansemann    has    observed    centrosomes  with 
spheres   of   attraction  and    rays  emanating  from 
them    in    the    leucocytes   of    young    granulation 
tissue ;    Heidenhain,  in  human  leucocytes  and  in 
those    of    the    salamander,    by     means    of    iron 
haemotoxylin  ;    after  examining  1,000  cells  in  a 
state  of  rest,    he    found  that  74'6  out  of  every 
FIG  2—  centroso-     100,  nac^  ^wo  unectual  centrosomes,  and  19'1  out 
mes  of  ceils  from  the     of  every  100  two  equal  centrosomes.     He  admits 

lymphoid    cortex     of  T 

the  liver  of  the  Saia-      as  a  rule,  there  are  two  centrosomes.      In  a  cer- 

mander  (after  Henne-       tain     number     of     cells,   by     the    side    of    the    t-WO 

guy).  J 

centrosomes,  he  has  seen  one  or  two  accessory 
corpuscles,  very  small,  and  almost  colourless.  The  three  or  four 
elements  are  joined  together  by  brownish  or  grayish  filaments, 
and  the  whole  (microcentre)  resembles  a  triangular  or  tetrahedric 
figure. 

In  the  lymphoid  cortex  of  the  liver  of  urodelic  amphibians, 
Henneguy  has  found  in  almost  all  the  cells  (leucocytes  having  a 
polymorphous  nucleus  or  basophilic  granules),  a  centrosome  which 
appears  like  a  coloured  point,  surrounded  by  an  aster.  The 
centrosome  as  a  rule  is  situated  in  the  concavity  of  the  nucleus. 
In  some  cells  in  which  the  nucleus  is  about  to  divide,  Henneguy 
has  seen  two  centrosomes  a  little  distance  from  each  other. 

The  Contents. — The  contents  of  the  leucocytes,  both  naturally, 
and  through  production,  are  exceedingly  variable  and  are  numerous. 
We  need  only  mention  for  the  present — the  particles  of  exocellular 
origin,  debris  of  microbes,  and  of  red  blood  corpuscles,  iron 
granules,  which  are  digested  by  the  white  corpuscle,  also  the 
presence  of  chromatin  granules,  excreted  by  the  nucleus  and  the 
protoplasm  (Nebenkern  of  certain  authors).  In  the  migratory  cells 
of  the  intestine  of  the  salamander  during  chromolysis,  Lukjanowhas 
seen  juxtanuclear  corpuscles  coloured  red-brown  by  the  stain  used 
by  Biondi  :  but  the  most  important  contents  are  without  doubt  the 
cytoplasmic  granules,  recognized  ever  since  Wharton  Jones  and  Max 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM     13 

Schultze  drew  attention  to  them,  and  since  studied  by  Semmer, 
Pouchet,  Ranvier,  Renaut  and  Hayem.  The  works  of  Ehrlich  and 
his  pupils  have  accurately  determined  their  histochemical  reactions 
and  especially  their  affinity  for  aniline  dyes,  and  in  studying  the 
behaviour  of  these  granules  towards  stains,  Ehrlich  has  recog- 
nized that  they  show  a  particular  predilection  for  certain  aniline 
colours.  Admitting  that  the  majority  of  these  colouring  matters 
are  salts,  he  has  for  the  sake  of  convenience  called  those  in  which 
the  principal  colouring  is  furnished  by  the  base,  basic  ;  those  in 
which  the  mixed  colour  is  due  to  the  acid  and  the  base,  neutral. 
Granules  are  termed  acidophiles,  basophiles,  or  neutrophiles,  accord- 
ing to  their  affinity,  that  is  to  say,  according  to  how  deeply  or 
how  exclusively  they  stain  with  one  or  other  of  these  colours, 
described  above  as  acid,  basic,  or  neutral.  Eosin,  orange,  acid 
fuchsin,  are  acid  colours  ;  methylene  blue,  safranin,  methyl  green, 
are  basic  colours.  Amphophiles  are  granules  which,  in  a  mixture  of 
acid  and  basic  colourings  at  the  same  time,  retain  the  two  colour- 
ing matters  :  the  coarse  refracting  granules  in  the  leucocytes  of 
Semmer  are  eosinophiles,  that  is  to  say,  acidophiles  ;  they  are  also 
called  oxyphiles,  but  Ehrlich  designates  them  by  the  Greek  letter 
a  ;  Ehrlich  has  also  found  two  sorts  of  basophilic  granules  :  7 
and  3  ;  the  granule  7  is  stained  by  basic  colours  without  change  of 
colour;  the  granule  B  shows  the  phenomenon  called  metachro- 
masis  :  it  is  coloured  red  by  the  polychromatic  blue  of  Unna. 
In  the  leucocytes  with  a  polymorphous  nucleus,  one  finds  a  fine 
granule  which  in  a  mixture  of  methyl  green,  orange  and  acid 
fuchsin  is  stained  violet  :  this  is  the  neutrophile  granule  e  of 
Ehrlich. 

The  neutrophile  of  this  granule  has  been  discussed  :  Gulland, 
Kanthack,  and  Hardy,  have  asserted  that  Ehrlich's  mixtures  were 
not  neutral,  but  acid,  and  that  in  reality  the  granule  e  was 
acidophile  (fine  oxyphile  granule).  Others,  Maragliano,  Zap- 
part,  etc.,  think  they  have  found  all  transitions  in  shape  and 
in  colour  between  a  and  e.  Perhaps  we  may  consider  this 
granule  e  amphophile  in  nature  ?  This  is  the  opinion  of  Dominici, 
who,  recalling  the  fact  that  Kanthack,  Hardy  and  sub-equently 
Jolly  have  stained  it  by  eosine,  adds  that  it  is  equally  well  stained 
by  basic  colours. 

There  is  still  another  granule  whose  significance  has  given 
rise  to  numerous  controversies  :  it  is  a  smaller  and  more  refracting 
granule  than  a,  which  in  leucocytes  with  polymorphous  nuclei,  in 


14  THE    LYMPHATICS 

the  blood  of  the  rabbit  and  of  the  guinea  pig,  has  been  described 
by  Ehrlich  and  Kurlow  under  the  name  of  pseudo- eosinophile, 
and  designated  by  the  letters  j3  E.  Is  this  acidophile  or  ampho- 
phile  ?  Should  it  be  classed  with  a  or  6  ? 

In  favour  of  a  should  be  mentioned  not  only  its  marked  acido- 
phile nature,  but  also  its  insolubility  in  water,  ammonia,  ether, 
alcohol,  chloroform,  turpentine,  formalin,  sublimate,  and  the  fact 
that  it  stains  yellow  by  iodo-iodide  solution.  If  differs  from  a  by 
its  solubility  in  acetic  acid,  by  the  fact  that  it  is  more  eosinophile 
than  orangeophile,  more  indulinophile  than  eosinophile. 

In  favour  of  e  must  be  noted  its  violet  colouration  by  the  triacid,1 
its  basophilism  which  some  consider  just  as  well  marked  as  its 
acidipholism.  In  a  mixture  of  blue  of  toloidin  and  eosin,  Dominici 
has  stained  it  a  violet  red  ;  it  differs  from  e  in  being  larger,  in  its 
insolubility  in  water,  and  in  its  acidophile  properties  being  more 
marked.  (Its  staining  by  eosin  is  not  hindered  by  the  haematoxy 
lin.)  It  differs  therefore  both  from  a  and  e. 

It  is  interesting  also  to  notice  its  presence  in  the  leucocytes  of 
the  guinea  pig  and  the  rabbit,  which  by  their  number,  dimensions, 
the  polymorphism  of  the  nuclei,  and  especially  by  their  physio- 
logical properties  (amiboism,  phagocytosis),  appear  to  be  the 
homologues  of  poly  nuclear  cells  with  neutrophile  granules.  Thus 
from  one  animal  type  to  another,  we  find  that  the  same  cell 
manufactures  products,  which  in  appearance  at  any  rate  differ 
from  each  other. 

In  birds,  various  crystalloids  appear  to  correspond  to  the  granule  a. 

We  may  also  observe  that  though  the  acidophile  granules  are  very 
scattered  in  the  animal  series,  and  we  find  them  not  only  in  the 
vertebrates,  but  also  in  crustaceans,  spiders,  insects,  oligochetae, 
sipunculae,  the  lamellibranchs,  the  psorobranchs,  basophilic 
granules  appear  to  be  peculiar  to  the  vertebrates  and  the  sipun- 
culae (Cuenot).  According  to  this  author,  the  white  corpuscles  of 
the  pulmonate  gasteropods  alone,  seem  to  be  destitute  of  granules. 
On  the  other  hand,  it  is  quite  possible  that  the  absence  which 
he  mentions  is  more  apparent  than  real,  for,  following  the  same 
line  of  thought,  Ehrlich  notices  the  fact  that,  though  Hirschfield 
did  not  find  neutrophile  granules  in  white  mice,  Miiller  has 
done  so  by  a  special  method. 

1  However,  if  I  may  judge  from  some  of  my  own  personal  observations,  its 
amphophilism  is  not  constant.  In  Biondi's  mixture,  after  fixation  with 
sublimate,  it  has  appeared  to  me,  to  be  stained  by  acid  fuchsin  only. 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM     15 

The  existence  of  these  granules  appears  clearly  proved,  seeing 
that  the  largest  of  them  are  visible  in  the  living  cell,  and  nearly 
all  may  be  made  apparent  by  methods  of  fixation  and'  by  many 
different  stains.  By  the  so-called  vital  stain,  from  neutral  red, 
the  majority  of  them  become  stained  an  orange  red,  a  few  red 
only  :  their  reaction  is  then  nearly  always  alkaline  (Ehrlich). 

Though  we  know  their  morphology,  their  affinity  for  colours,  and  their 
solubilities,  we  are  still  very  ignorant  of  their  true  nature  :  perhaps  they  are 
albumins  (Weiss,  Lowit,  Sciawcillo).  It  is  almost  certain  that  they  are  not 
debris — blood-cellular  or  microbic,  or  former  phagocytes,  as  has  been  thought 
bySacharoff,  Hardy,  Lew  Bonn  Keng,  Tettenhamer,  Metchnikoff  and  Mensil. 
Are  these  bodies  constituents  or  products  of  cytoplasm  ?  Some  have  wished 
to  identify  them  with  the  bioblasts  of  Altmann  ;  Arnold,  observing  their 
arrangement  (tendency  to  form  little  chains  ?),  and  their  relations  with  the 
stable  cellular  bodies,  thinks  they  represent  transformed  plasmosomes  :  this 
opinion,  adopted  by  Schultze  and  Gulland,  is  contested  by  Ehrlich,  Renaut, 
Lowit,  and  Heideiihain :  Ranvier  thinks  the  question  is  one  of  cellular  secretions. 
Some  cells  seem  to  owe  their  preservation  to  the  reserve  material  they  possess, 
as  is  the  case  with  vitelline  granules.  Others  are  expelled  with  or  without 
preliminary  dissolution.  In  the  same  way,  granules  secreted  by  certain 
granular  cells  dissolve  themselves. 

We  may  ask  again  whether  these  granules  represent  a  particular  elaboration, 
or  whether  they  should  be  regarded  as  forming  a  substratum  of  soluble  fer- 
ments, the  presence  of  which  in  the  protoplasm  of  leucocytes  is  demonstrated 
by  chemistry.  In  this  connection  it  is  as  well  to  remember  that  those  white 
corpuscles,  which  have  no  granules,  have  the  power  of  digestion,  well  marked  : 
again  the  macroeytes  (cells  of  Metchnikoff)  which  appear  to  possess  a  soluble 
ferment  are  capable  of  dissolving  red  blood  corpuscles  (macrocytase  of 
Tarassewitch).  On  the  other  hand,  there  are  ferments  in  the  nucleus  which 
has  no  granules. 

After  all,  what  is  the  physiological  value  of  distinctions  established  by  the 
study  of  colour  reactions  ?  Without  attempting  to  settle  this  question  off- 
hand, we  must  remark  that  differences  in  staining  do  not  always  imply  im- 
portant differences  in  chemical  constitution,  seeing  that  a  simple  dehydra- 
tion is  quite  sufficient  to  alter  the  staining  affinities  of  a  granule  :  besides 
differences  of  chemical  constitution  do  not  always  correspond  to  different 
physiological  meanings :  Haemoglobin  of  man  does  not  crystallize  like 
that  of  the  guinea  pig,  yet  both  serve  the  same  purposes.  May  not  we  sup- 
pose that  the  same  is  true  for  the  granules  /?E  and  e  ?  But  the  existence  of 
granules  in  white  corpuscles  has  raised  other  problems  :  It  has  been  a  moot 
point  if  cells  with  granules  always  come  from  granular  cells,  and  if  two  kinds  of 
granules,  €  and  8  for  example,  can  be  met  with  in  the  same  cell.  If  it  is  quite 
certain  that  the  granular  cells  can  again  reproduce  themselves,  it  seems  almost 
proved  that,  originally  these  cells  are  derived  from  non-granular  elements.  The 
place  of  production  of  these  granules  has  given  rise  to  much  discussion  :  it  does 
not  seem  probable  that  it  habitually  takes  place  in  the  blood.  It  is  in  the 
marrow  of  bones,  sometimes  even  in  the  glands,  and  in  the  spleen  that  these 
granules  develop.  Can  two  different  granules,  viz.  e  and  8,  e  and  a  coexist  in 
the  same  cell  ?  At  first  sight  it  seems  easy  to  reply  in  the  affirmative,  seeing 
that  a  number  of  authors  (Ehrlich,  Schwarze,  Weiss,  Schaffer,  Fischl,  Miiller, 
Hirschfield,  Bettmann,  Arnold,  Engel,  Levaditi,  Jolly)  have  found  in  the 


16  THE    LYMPHATICS 

same  cytoplasm  two  granules  having  inverse  colouring  affinities.  In  reality, 
however,  the  solution  to  this  question  is  more  complex,  for  the  presence  of 
basophile  granules  in  an  eosinophilo  cell  does  not  necessarily  prove  the  co- 
existence of  granules  a  and  8.  To  demonstrate  this  fact,  it  should  be 
proved  that  the  superadded  basophilic  granule  is  identical  with  the  true  8, 
not  only  in  its  colouring  properties,  but  also  in  its  morphology,  and  especially 
in  its  chemical  properties  (solubility  or  insolubility).  Thus,  for  example, 
Arnold  finds  basophile  granules  by  the  side  of  granules  a  or  y3E,  these  not 
being  metachromatic  are  not  identical  with  8.  Engel  finds  in  the  same  cell, 
granules  8,  e,  and  a,  but  as  the  histochemical  characters  are  not  given,  it  is 
impossible  to  know  if  the  superadded  granules  are  the  true  e  and  a.  More- 
over, it  can  be  understood  how  complex  the  question  becomes,  when  even 
the  coexistence  of  a  and  e  is  in  question.  We  know  that  c  has  in  turn  been 
regarded  as  neutrophile,  acidophile,  and  amphophile. 

Though  it  has  not  been  demonstrated  that  two  granules  distinct  and 
classified  (a,  /?,  etc.)  can  coexist  in  the  same  element,  it  is  quite  certain 
that  the  same  element  can  contain  granules  which  colour  differently. 
What  is  the  significance  of  superadded  granules  which  are  still  called 
heterochromatic  ? 

Ehrlich  having  found  indulinophile  granules  in  the  young  eosinophiles, 
and  having  shown  that  they  had  the  chemical  reactions  of  a,  and  that  when 
dehydrated,  the}'  distinctly  became  eosinophiles,  thought  that  they  were 
young  forms  in  process  of  development.  We  know  that  other  elements,  such 
as  the  red  blood  corpuscles,  are  polychromatophile  before  becoming  acidophiles. 
Bettman  thinks  on  the  contrary,  that  the  presence  of  basophile  granules  is  a 
sign  of  degenerative  process. 

Is  this  always  so  ?  It  would  seem  not  to  be  the  case.  Quite  recently  Leva  • 
diti  has  observed  Ehrlich's  cells  (Mastzellen)  which  contained  granules, 
colour  reddish-violet  by  the  triacid,  and  violet-red  by  the  eosin  blue  of  methyl- 
methylene.  They  resemble  t  not  only  in  their  staining  affinities,  but  also  in 
their  solubility  in  potash  (2-100)  and  in  acetic  acid  (3-100):  they  differ 
however  in  staining  deeper  red  with  the  triacid,  in  their  insolubility  in 
distilled  water,  and  in  their  larger  size  :  they  differ  from  8  in  their  colour  and 
their  shape:  they  resemble  8  in  their  solubility  in  acetic  acid.  Levaditi 
thinks  they  are  new  granules,  which  bear  no  relation  to  those  already 
known.  While  noting  these  mixed  and  complicated  characteristics,  we  may 
perhaps  ask  whether  forms  intermediate  between  those  of  8  and  e  cannot 
exist  ?  For  will  it  not  be  granted,  that  it  is  a  property  of  intermediate  forms 
to  present  mixed  characters,  which  are  no  longer  entirely  those  of  the  primi- 
tive form,  but  which  already  bear  some  resemblance  to  those  in  a  later 
stage  of  development  ?  Moreover,  one  can  well  understand  how  by  their 
nature,  such  characteristics  leave  the  field  open  to  arbitrary  interpretations, 
and  the  question  of  whether  they  are,  or  are  not,  transitional  forms  amongst 
the  various  kinds  of  granules  pointed  out  by  Ehrlich,  will  for  some  time 
remain  a  source  of  discussion. 


Physical  Properties. — Nearly  always  colourless  but  some- 
times tinted,  of  a  variable  refraction,  opaque  or  clear,  the  leucocytes 
are  soft,  protoplasmic,  extensible  masses,  with  no  covering.  They 
are  heavier  than  plasma  but  lighter  than  red  blood  cells  :  they  are 
viscous  and  adhere  to  the  smoothest  surfaces.  When  the  circulation 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM  17 

slackens,  they  accumulate  against  the  vessel-wall,  and  resist  the 
current  which  carries  them  along.  Placed  upon  a  glass  slide, 
they  adhere  to  it.  and  are  not  carried  away  by  a  drop  of  water, 
which  by  its  capillary  action  drives  away  the  red  corpuscle.  As  the 
researches  of  Berthold  seem  to  show,  that  a  protoplasmic  drop, 
denuded  of  membrane,  possesses  the  physical  characteristics  of  a 
liquid,  it  may  be  supposed  that  at  rest,  the  leucocyte  is  rounded 
by  the  superficial  tension  being  equal  at  all  points  on  its  surface  ; 
this  tension  is  similar  to.  but  weaker,  than  that  of  globules  of  butter 
suspended  in  milk.  Though  this  illustration  is  suggestive,  it  is 
not  absolutely  correct,  for  as  we  have  seen,  the  protoplasm  of 
the  leucocyte  is  far  from  being  homogeneous. 

Chemical  Constitution. — Though  still  far  from  perfect,  our 
knowledge  of  the  chemical  constitution  of  leucocytes  has  in  recent 
years  been  enriched,  by  interesting  theories  not  only  in  cell,  but 
also  in  general  physiology. 

In  1871,  Hoppe-Seyler  analyzed  globules  of  pus  which  he  separated  from 
the  liquid  which  contained  them.  He  found  in  100  parts  of  leucocytes — 

13*762  undetermined  albuminoids. 

34-257  nuclein. 

20*566  insoluble  substances. 

14-384  lecithin  and  fat, 
7 '400  cholesterin. 
5*  190  ccrcbrin. 
4*433  extractives. 

The  ash  contains  phosphoric  acid,  chlorine  and  numerous  metals  (sodium, 
potassium,  calcium,  magnesium,  iron).  Quite  recently,  Stassano  and  Bourcefc 
have  found  in  the  leucocytes  of  normal  blood  another  metalloid,  iodine. 

As  regards  iron,  the  researches  of  Arnold,  Hayem,  Quiucke,  Barker, 
Hansermann,  prove  its  presence  in  leucocytes,  to  be,  if  not  constant,  at 
least  frequent.  Arnold  has  seen  leucocytes  ingest  exogenous  iron,  and  Rouget 
has  shewn  that  the  same  cells  absorbed  the  old  red  corpuscles  ;  and  all  patho- 
logists  after  Vircho\v,  know  that  residual  pigments  of  old  ha?morrhagic  foci 
are  carried  away  by  leucocytes.  According  to  Quincke,  red  blood  corpus- 
cles after  being  eaten  are  transformed,  some  into  yellow  granules,  others 
into  colourless  albuminate  of  iron,  which  can  only  be  detected  by  histo- 
chemical  analysis.  Barker  believes  in  the  presence  of  iron  in  eosinophile 
granules.  Hayem  says  that  certain  leucocytes  are  overcharged  with 
haemoglobin,  especially  after  bleeding.  These  last  statements,  and  all  those 
old,  or  new,  which  being  founded  on  mere  appearances,  or  colour  reactions, 
allow  us  to  infer  the  haemoglobic  degeneration  of  leucocytes,  should  be 
received  with  the  greatest  caution.  It  is,  however,  fairly  certain  that  the 
protoplasm  of  leucocytes  may  contain  the  most  various  kinds  of  metals,  iron 
frequently,  if  not  always.  This  statement  is  not  without  interest,  now 
that  we  are  aware  that  their  protoplasm  is  rich  in  soluble  ferments.  Wo 
may  in  fact,  suppose  that  there,  the  metal,  as  shewn  in  the  experiments  of 
Bertrancl,  and  Hanriot.  plays  a  part  in  the  action  of  the  diastase.  Before 


18  THE    LYMPHATICS 

studying  these  diastases,  we  ought  to  say  a  word  about  the  ternaiy  and  qua- 
ternary substances  of  the  leucocyte.  As  regards  ternary  substances,  the 
white  corpuscle  may  contain  fats  and  glycogen. 

The  leucocyte  of  invertebrates  sometimes  accumulates  fat  in  reserve 
without  undergoing  degeneration,  exactly  as  the  adipose  connective  tissue  cell 
of  higher  vertebrates  does.  Cuenot  expressly  mentions  that  this  is  the 
case  with  the  leucocytes  of  Tuniciers.  Nevertheless,  the  same  author  remarks 
that  in  some  leeches,  and  in  some  of  the  molluscs  (cloris  tuberculata),  ascidies, 
and  batrachians,  the  fat  is  specially  seen  in  old  cells,  or  in  cells  of  anaemic 
animals — and  in  fact,  among  the  higher  vertebrates,  fat  is  scarcely  seen 
except  in  disease  or  in  dying  leucocytes ;  it  is  not  an  addition,  but  obviously 
a  fatty  degeneration.  In  the  same  way,  the  dead  leucocytes  from  pus  are  very 
rich  in  fat.  Nevertheless,  in  mammals  the  white  corpuscles,  which,  traversing 
the  intestinal  epithelium,  absorb  fat  from  the  lacteals,  are  an  exception  to  this 
rule. 

In  the  lymphatic  cell  of  cold  blooded  animals,  Ranvier  has  noticed  that 
the  glycogen  which  was  sticky,  was  somewhat  diffused.  In  mammals, 
glycogen  does  not  exist  constantly  in  the  protoplasm  of  the  leucocytes.  After 
injection  with  chloride  of  sodium,  staphylococcus,  and  streptococcus,  Salmon 
has  seen  glycogen  appear  in  the  lymphocytes,  and  in  the  polynuclear  cells, 
but  never  in  the  macrophages.  This  simple  fact  should  suffice  to  show  how 
wrong  this  author  is  in  maintaining  that  the  glycogen  takes  a  part  in  the 
mechanism  of  the  defence  of  the  organism,  by  means  of  the  white 
corpuscles.  All  facts  point  to  the  contrary.  In  pus,  the  quantitative  varia- 
tions of  glycogen  are  considerable  (Kiihiie,  Jaft'e,  Kramer,  Lilienfield). 
Huppert  has  seen  variations  between  mere  traces  and  T67  gr.  The  glycogen 
of  the  leucocytes  appears  under  the  most  diverse  morbid  circumstances  (nar- 
coses,  diabetes,  severe  contusions,  etc.). 

According  to  Salmon,  this  glycogen  presents  itself  in  various  forms,  viz. 
as  crescents,  concentric  rings  with  a  cellular  outline,  or  even  balls,  or 
excrescences  which  remind  us  of  amoebic  prolongations.  Sometimes  these 
balls  leave  the  leucocyte  and  fall  into  the  plasma. 

The  mahogany  brown  colour  which  iodine  gives  to  glycogen  becomes  pale 
between  50°  and  60°  (Errera)  ;  and  disappears  between  65°  and  73°  (Can- 
trian). 

This  glycogen  appears  to  be  very  stable  (Lepine),  and  it  probably  has 
several  sources ;  the  leucocyte  is  in  fact  capable  of  absorbing  either  glucose, 
or  starch.  We  shall  see  that  it  can  convert  the  latter  into  sugar.  We 
may  then  ask,  can  this  white  cell,  like  the  liver  cell,  by  hydrolysis,  transform 
the  sugars,  ingested  by  it,  into  glycogen  ?  It  can  be  clearly  seen,  that  after 
the  peritoneal  injection  of  glucose,  the  Ieuc9cytes  become  charged  with 
glycogen ;  but,  as  the  same  thing  happens  after  a  simple  injection  of  sodium 
chloride,  we  should  be  cautious  in  our  interpretation  of  the  fact. 

On  the  other  hand,  we  may  imagine  that  this  glycogen  is  formed  at  the 
expense  of  some  of  the  albumins  in  the  leucocytes  ;  in  fact,  Kossel,  has  shown 
that  nuclein  and  histon  become  decomposed  in  exonic  bases,  with  which  it  is 
interesting  to  compare  the  products  of  the  decomposition  of  polysaccharic 
bodies. 

We  know  that  Hoppe-Seyler  mentions  the  existence  of  an  undetermined 
albuminoid  and  of  a  nuclein  ;  Gautier  calls  them  nucleo-albumins  (hyaline 
substance  of  Rovida,  globulin  of  Halliburton).  This  study  has  been  developed 
by  Hofmeister,  Lilienfeld  and  Kossel. 

Hofmeister  has  found  abundant  peptones  in  the  leucocyte.     Lilienfeld 


GENERAL  ANATOMY  OF  THE  LYMHPATIC  SYSTEM     19 

has  obtained  from  the  aqueous  extract  of  leucocytes,  after  centrifugalizing 
and  filtration,  and  then  precipitating  by  acetic  acid,  a  white  powder  insoluble 
in  acids,  but  soluble  in  water  and  weak  alkalies;  this  is  the  nucleohiston  which, 
treated  by  alkalies,  dilute  acids,  or  boiling  water,  splits  up  into  leuconuclein. 
(acid),  and  the  liiston  of  Kossel  (basic).  There  is  in  every  100  parts  of  leu- 
cocyte 68*8  of  leuco-nuclein  and  8'7  of  histon. 

The  iiuulein  is  capable  of  giving  rise  to  uric  acid.  The  elimination  of 
this  acid  in  the  urine  increases  considerably  in  certain  leuchaemias.  Thus, 
we  may  imagine  that  the  leucocyte  plays  a  part  in  the  process  of  the  break- 
ing up  of  nitrogen  within  the  organism. 

From  another  point  of  view,  it  is  no  less  curious  that  nuclein  and 
histon,  two  protamines,  which  come  from  the  same  cell,  or  at  least  from 
the  same  kind  of  cell,  possess  antagonistic  physiological  properties :  —  the 
former  favours  coagulation,  while  the  latter  hinders  the  process. 

Normally,  there  are  pigments  in  some  of  the  leucocytes  of  cold  blooded 
animals  (Cuenot,  Renaut),  and,  abnormally  (foreign  bodies,  melanin),  in 
those  of  warm  blooded  animals. 

It  is  now  a  well  established  fact  that  leucocytes  produce,  or  at  any  rate 
contain,  soluble  ferments,  and  that  consequently,  they  are  capable  not  only 
of  absorbing  foreign  bodies,  but  also  of  actually  digesting  some  of  them. 

Heckel,  who  has  seen  blue  granules  of  litmus  which  have  been  digested 
by  leucocytes  become  red,  thinks  that  such  digestion  takes  place  in  an  acid 
medium.  Metchnikoff  thought  at  one  time  it  took  place  in  a  neutral  or 
alkaline  medium  ;  but  having  since  recognized  that  the  vacuoles  were 
coloured  brick  red  by  the  neutral  red,  he  too  now  thinks  that  it  takes  place 
in  a  slightly  acid  medium. 

Ever  since  1888,  Leber  has  affirmed  that  aseptic  pus  digested  fibrin  and 
liquefied  gelatine;  these  properties  he  found  were  destroyed  by  heat.  In  the 
leucocytes  of  the  tonsils,  Kossbach  has  found  an  amylase ;  and  more  recently 
Zobolotny  has  found  the  same  in  the  peritoneal  leucocytes  of  the  guinea  pig. 
It  would  seem  that  the  effects  of  this  ferment  are  sometimes  somewhat  slow 
in  manifesting  themselves ;  but  perhaps  it  does  not  exist  in  all  leucocytes 
and  in  all  animals.  Such  is  doubtless  the  explanation  of  the  negative 
results  announced  by  Schoefer,  Xetchaeff  and  Salmon  :  nevertheless 
Salmon  has  seen  ingested  starch  become  dextrin. 

According  to  Lepine,  the  glycoly tic  diastase,  manufactured  by  the  pancreas 
is  apparently  fixed  in  a  provisional  manner  by  the  white  corpuscle.  Portier, 
and  later  on  Brandenburg,  have  studied  the  oxidizable  ferments  of  leucocytes. 
Mantegazza  and  Schmidt  those  of  the  plasma.  The  plasmase  has  been 
found  by  Jacob,  Lowit,  and  Schattenfroh  in  extracts  of  leucocytes  ;  it  would 
seem  to  be  very  abundant  in  the  nuclei.  This  fact  proves  that  one  must  be 
slow  in  establishing  a  connexion  between  the  presence  of  these  ferments 
and  those  of  cytoplasmic  granules.  Just  as  the  holocrine  glands,  in  order 
to  set  free  the  products  of  their  elaboration,  destroy  themselves,  so  the  leuco- 
cytes have  to  die,  so  that  the  plasmase  may  become  diffused  into  the  sur- 
rounding liquid.  Also  we  have  been  enabled  to  state,  that  the  coagulability 
of  blood  is  more  rapid,  in  proportion  as  the  white  corpuscles  offer  less  re- 
sistance. In  the  macrocytes,  Delezenne  has  found  the  enterokynase,  and 
Tarassewitch,  the  macrocytase.  In  aseptic  pus,  obtained  by  injection  of 
turpentine,  Achalme  has  found  the  amylase,  the  oxydases,  the  ferment 
liquefying  gelatine,  and  also  a  ferment  allied  to  trypsin,  a  casein  and  a  saponin. 

Cuenot  and  Cattaneo  think  that  in  the  white  corpuscles  of  crustacean 
decapods  there  is  a  ferment  which  forms  haemocyaiiin.  Thus,  in  spite  of  indi- 


20  THE    LYMPHATICS 

vidual  variations,  leucocytes  can  take  on  the  many  functions  of  hepatic, 
pancreatic  and  renal  cells,  functions  which  they  exercise  not  only  in  definite 
places,  but  actually  within  the  tissues  themselves.  In  fact,  like  the  hepatic 
cell,  they  are  capable  of  manufacturing  glycogen,  of  storing  up  fat;  and  like 
the  pancreatic  cell,  they  can  produce  anamylase  and  yield  a  glycolysin;  like 
the  renal  cell,  they  can  take  part  in  the  ultimate  mutations  of  nitrogenous 
matter,  inasmuch  as  they  give  rise  to  uric  acid.  These  unicellular  glands 
are  then,  not  simply  organs  of  assimilation  and  storehouses  for  the  accu- 
mulation of  nutritive  stores,  but  they  are  also  excretory  organs. 


Biological  Properties. — The  white  cell  possesses  all  the  prim- 
ordial properties  of  living  matter  :  sensibility,  mobility,  powers  of 
absorption,  of  secretion,  of  reproduction. 

Mobility. — This  has  been  recognized  for  a  long  time,  in  fact,  ever 
since  Wharton  Jones  in  1846,  observed  the  pseudopodic  displace- 
ments and  expansions  of  leucocytes  in  the  blood  of  the  ray-fish 
and  of  the  frog.  Some  years  later,  in  1850,  Davaine  made  the  same 
observations  in  the  white  corpuscles  of  human  blood.  These  changes 
of  form  were  compared  by  Lieberkiihn  to  those  of  amoebae,  and 
now.  they  are  known  by  the  term  Amiboism,  or  amoebic  movement. 
The  leucocvte  becomes  spheroidal,  throws  out  a  prolongation  or 
pseudopod,  which  ramifies  :  then  the  cellular  body  becomes  displaced 
and  blends  with  this  expansion,  and  so  on.  At  one  time,  the 
protoplasmic  expansions  are  lobed,  rounded  and  fairly  large  ;  at 
another,  they  are  broken  up,  or  are  filiform,  like  needles.  The 
pseudopods  of  eosinophiles  appear  to  be  less  slender  than  those 
of  other  leucocytes  (Max  Schultze,  Jolly).  According  to  Flemming 
and  de  Bruyne,  there  are  no  lobopods  in  circulating  blood  ;  the  fine 
pseudopods  are  produced  in  corpuscles  which  have  left  the  vessels. 
Side  by  side  with  these  movements,  there  appear  to  exist  endo- 
plasmic  movements  which,  without  displacing  the  cell,  displace  the 
granule  and  perhaps  the  nucleus  also. 

According  to  Ranvier,  this  nucleus  exhibits,  under  the  influence 
of  these  protoplasmic  movements,  passive  changes  ;  the  buds,  the 
constrictions,  and  even  the  divisions  which  are  seen,  result  from 
the  activity  of  the  protoplasm  which  constricts,  by  a  kind  of  con- 
traction, portions  of  the  nuclear  mass  just  as  a  ring  does  a  sac. 
Sherrington,  Dekhuysen,  Gulland  and  Korschelt  think  the  same  ; 
Jolly  sees  in  the  polymorphism  of  the  nucleus  a  sign,  and  even  in 
fact,  a  result  of  the  amoebic  activity  of  the  cellular  protoplasm. 

Metchnikoff ,  and  Heidenhain  find  in  the  appearance  of  the  multi- 
lobed  nucleus  one  of  the  indications  of  the  adaptation  of  leucoytes 
to  diapedesis.  Ehrlich  long  ago  remarked  that  the  poly  nuclear 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM    21 

leucocytes  shift  their  position  more  frequently  and  in  greater  num- 
bers than  is  the  case  with  other  leucocytes.  Metchnikoff  insists 
on  the  relative  rarity  of  this  nuclear  type  amongst  a  vascular  inverte- 
brates, and  thinks  it  evident  that  a  nucleus,  which  is  broken  into 
several  fragments,  must  traverse  the  vascular  wall  much  more 
easily  than  a  large  entire  nucleus. 

It  is  quite  evident  that  neither  the  theory  of  Ranvier,  nor 
that  of  Metchnikoff  can  explain  the  genesis  of  all  the  polymor- 
phous nuclei.  Do  they  hold  good  for  any  of  them  ? 

The  observations  of  Ranvier  and  Jolly  show  the  concomitance 
of  nuclear  and  protoplasmic  modifications,  without  establishing 
any  evidences  of  casual  relationship.  In  fact,  they  take  for  granted, 
but  do  not  prove  the  passivity  and  immobility  of  the  nucleus  ; 
they  do  not  explain  the  polymorphism  of  the  nucleus  of  certain 
immobile  cells,  and  the  almost  absolute  spheroidal  shape  of  the 
nucleus  of  certain  amoebic  cells  ;  Demoor,  however,  after  para- 
lyzing the  protoplasm  of  the  leucocyte  by  chloroform,  has  seen 
movements  of  the  nucleus.  While  admitting  with  Jolly,  that  in 
the  case  of  the  leucocytes  of  the  frog,  these  observations  must 
be  received  with  caution,  it  is  none  the  less  certain  that;  at  certain 
periods  of  its  life  (direct  and  indirect  division),  the  nucleus  has  the 
power  of  movement. 

Jolly  attempts  to  explain  the  twisted  shape  of  the  nucleus  of 
immobile  cells  by  supposing  that  the  nucleus  has  not  had  time  to 
return  to  its  rounded  shape.  It  is  quite  possible  that  this  expla- 
nation may  be  true  in  some  particular  cases,  but  no  generaliza- 
tions should  be  made.  Besides,  this  polymorphous  nucleus  is 
seen  in  cells  which  have  never  been  mobile.  When  he  discusses 
the  rounded  shape  of  the  nucleus  of  amoebic  cells,  Jolly  expresses 
the  opinion  that  cells  cannot  exhibit  exoplasmic  movements  without 
influencing  the  nucleus.  Though  doubtless  such  movements  exist, 
the  main  point  to  be  settled  is.  whether  the  mononuclear  cells 
travel  solely  by  means  of  similar  movements.  As  so  little  is  known 
about  this  question,  we  may  conclude  with  Lavdovsky,  Hardy  and 
Wresbrock  that,  contrary  to  the  opinion  of  Ranvier,  it  is  not  yet 
proved  that  abnormal  nuclear  shapes  are  purely  passive  formations, 
or  are  directly  dependent  on  protoplasmic  contractility. 

The  theory  of  Metchnikoff  is  open  to  the  same  and  other  ob- 
jections besides.  We  will  not  return  to  the  question  of  the  dia- 
pedesis  of  mononuclear  cells,  or  to  the  polymorphism  of  the 
.nucleus  of  certain  immutably  fixed  cells,  but  will  content  ourselves 

c 


22  THE    LYMPHATICS 

with  the  remark  that,  though  certain  shapes  of  polynuclear  cells 
appear  well  adapted  for  their  passage  across  narrow  intercellular 
spaces,  there  are  others  (shaped  like  an  0  in  rose  work)  which,  are 
certainly  not  adapted  for  endothelial  migrations. 

To  change  their  position,  the  leucocytes  make  a  considerable  effort 
(Engelmann).  To  understand  this,  we  must  remember  that  they 
possess  a  superficial  tension,  feebler,  but  of  the  same  kind  as  fat 
globules  suspended  in  an  aqueous  liquid.  In  a  damp  chamber. 
Lavdovsky  has  seen  leucocytes  pass  through  and  through  a  clot  of 
blood.  The  white  corpuscles  of  cold-blooded  animals  manifest  their 
amoebic  movements  at  the  surrounding  temperature  ;  those  of 
warm-blooded  animals  only  between  20°  and  37°.  Heat  excites 
this  activity  ;  a  temperature  of  43°  kills  them,  producing  at  the 
same  time  a  round  shape.  Oxygen  is  necessary  for  their  life,  and 
especially  for  a  manifestation  of  their  motor  powers  ;  thus  if  a  small 
piece  of  phosphorus  be  introduced  under  the  skin,  absolutely  no 
leucocytes  will  arrive  on  the  spot,  because  phosphorus  absorbs  all 
the  oxygen  in  the  neighbourhood. 

Rollett,  Goluber  and  Engelmann  have  stated  that  under  the 
influence  of  inductive  shocks,  leucocytes  withdraw  their  pseudopods 
and  assume  a  spherical  form  :  strong  currents  kill  them  :  weaker 
ones  momentarily  paralyze  them.  Ranvier  thinks  it  is  difficult  in 
such  experiments  to  entirely  eliminate  causes  of  error  of  chemical 
origin  (electrolytic  action  of  the  current,  etc.). 

Carbonic  acid,  carbon  monoxide,  hydrogen,  quinine,  curare,  and 
chloroform  paralyse,  and  then  kill  the  leucocytes. 

The  aqueous  humour  of  the  frog  is  an  unfavourable  medium  for 
these  cells. 

Owing  to  their  mobility,  the  leucocytes  are  well  called  migratorv 
cells  ;  they  frequently  leave  the  lymph  and  the  blood  to  diffuse 
themselves  into  the  neighbouring  tissues  (Recklinghausen,  Waller, 
Cohnheim,  Strieker  and  Sanderson,  Metchnikoff,  Sabatier,  Pouchet, 
Kowalewsky,  Durham,  etc.).  As  is  proved  by  a  series  of  classical 
experiments,  they  can  traverse  porous  bodies  ;  at  one  time,  they 
move  in  intercellular  spaces,  (arai^aTa) :  at  another,  they  perforate 
cellular  protoplasm  (fenestrations  of  intestinal  cells)  :  a  certain 
number  of  them  definitely  leave  the  internal  medium  to  lose  them- 
selves— for  good  and  all  one  may  say — on  the  exterior,  either  on 
a  cutaneous  surface  or  within  the  intestinal  canal.  Thus  we  may 
conceive  of  the  possibility  of  an  elimination  brought  about  by  leuco- 
cytes. 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM     23 

Durham  stated  that  in  this  way  leucocytes  excreted  foreign 
substances,  which  had  been  experimentally  introduced  in  to  the  body 
of  Asterias  rubens.  White  corpuscles  with  similar  functions  have 
been  noticed  in  the  ovary  of  Lacerta  agilis,  and  of  mammals,  by 
Strahl  and  Lowenthal. 

Now,  is  mobility  a  property  common  to  all  leucocytes  without 
exception  ?  The  problem  is  difficult,  because  it  is  always  a  difficult 
matter,  without  staining,  to  know  with  which  variety  of  leucocyte 
one  is  dealing.  Under  these  conditions,  for  example,  it  is  impossible 
to  know  if  one  is  observing  an  eosinophile  or  a  leucocyte  with 
basophilic  granules,  or  even  a  small  leucocyte  with  neutrophilic 
granules. 

The  most  amoebic  of  all  are  the  corpuscles  with  neutrophile 
granules.  Next  come  the  large  corpuscles  without  granules,  and. 
the  eosinophiles.  In  opposition  to  Renaut's  views,  the  amoebic 
character  of  the  latter  has  been  shown  by  Max  Schultze,  Bizzozero, 
Mayer,  Weiss,  Miiller  and  Rieder,  Lavdovsky,  and  Jolly. 

From  his  researches  on  leuchaemic  blood,  Jolly  came  to  the  con- 
clusion that  as  a  general  rule,  the  small  corpuscles  without  granule, 
are  not  mobile  ;  sometimes,  however,  he  has  seen,  as  Rieder  has, 
small  mobile  corpuscles.  This  fact  has  lately  been  confirmed  by 
Hirschfield  and  Wolff. 

The  amoebic  character  of  leucocytes,  which  has  been  affirmed  by 
great  observers,  is  easy  to  verify,  and  is  a  positive  fact,  which  the 
dissentient  opinions  of  Semper,  Griesbach  and  Retterer  cannot 
shake.  We  may  remember  that,  according  to  Griesbach,  the 
migration  observed  in  vitro,  is  only  the  result  of  adherence,  and  of 
the  diffusion  and  absorption  of  gas,  and  that,  according  to 
Retterer,  the  pseudopodic  expansions  are  only  "  the  result  of  hydra- 
tion,  and  of  the  disintegration  and  exhaustion  of  the  cellular  body." 

Now.  can  we  conceive  the  mechanism  of  this  mobility  to  be  an  elementary 
manifestation  of  a  contractile  substance  of  the  most  primitive  kind  ?  Engel- 
mann  has  attempted  to  apply  to  the  movements  of  this  protoplasm,  deprived 
of  double  refraction,  his  thermodynamic  theory  of  muscular  contraction. 
He  supposes  that  there  exists  in  the  protoplasm  of  the  amoeboid  cell,  innumer- 
able contractile  elements,  too  small  to  be  visible  even  under  the  strongest 
magnifying  powers  ;  these  elements,  are  heaped  up  without  order,  and  are 
elongated,  and  when  they  swell  become  spherical.  From  this  swelling  results  the 
formation  of  pseudospores.  It  will  be  seen  that  these  are  pure  hypotheses  which, 
are  rejected  with  reason,  by  Ver worn.  To  the  latter  author  we  are  indebted  for 
a  theory  which  at  least  is  very  ingenious.  He  thinks  that,  the  mobility  of  the 
leucocytes,  like  all  the  phenomena  of  contraction,  results  from  the  alternation 
of  two  opposite  phases;  one,  that  of  contraction,  in  which  the  surface  dimin- 


24  THE    LYMPHATICS 

ishes  in  relation  to  its  mass  (spherical  form),  the  other,  that  of  expansion  in 
which  the  surface  increases  (pseudopodic  formations).  The  leucocytes,  having 
a  superficial  tension  analogous  to  that  of  liquids,  we  may  suppose  that  when 
they  are  spherical,  they  possess  a  superficial  tension  equal  at  all  points 
of  their  surface.  In  the  same  way,  when  they  throw  out  a  pseuclopod,  it  is 
because  their  superficial  tension  diminishes  at  this  point.  What  then 
are  the  causes  of  this  augmentation  or  diminution  of  superficial  tension  ? 
Tf  we  grant  that  pseudopods  form  in  presence  of  oxygen,  and  disappear  in 
its  absence,  and  taking  this  gas  as  an  example,  Yerworn  supposes  that  it 
is  the  unilateral  excitant  capable  of  diminishing  the  superficial  tension  at  any 
one  point  of  the  surface  of  the  leucocyte,  and  consequently  of  producing  pseu- 
dopods. It  would  diminish  the  superficial  tension,  and  at  the  same  time 
lessen  the  cohesion  which  exists  between  the  different  organic  molecules. 

Under  the  influence  of  oxygen,  or  of  excitants  of  de-assimilation,  the  organic 
molecules  would  decompose  spontaneous!}7,  the  superficial  tension  increase, 
and  the  leucocyte  again  become  spherical  owing  to  the  retraction  of  the  pseu- 
clopod previously  formed.  Like  all  theories,  that  of  Yerworn  is  open  to  certain 
objections  ;  in  the  first  place,  the  protoplasm  of  the  leucocyte  is  not  homoge- 
neous ;  and  secondly,  we  do  not  know  for  certain  in  what  manner  the  oxygen 
diminishes  the  superficial  tension,  etc.  However,  the  theory  has  the  merit 
of  being  suggestive,  and  of  showing  or,  at  least,  attempting  to  explain  the 
meaning  of  chemiotaxic  phenomena,  positive  or  negative.  Chemiotaxis 
is  not  a  mysterious  attraction  or  repulsion  ;  it  comes  from  the  kind 
of  movement  peculiar  to  the  cellular  form  considered.  In  the  instance 
given  above,  the  one  sided  excitant  is  oxygen  which,  by  diminishing  the 
superficial  tension,  brings  about  the  appearance  of  a  pseudopod  on  the 
excited  side  ;  the  leucocyte  moves  towards  the  oxygen,  and  then  is  said 
to  have  a  positive  chemiotaxis.  Now,  there  are  unilateral  excitants  which, 
on  the  contrary,  increase  the  superficial  tension  at  the  excited  point :  the 
pseudopod  forms  on  the  opposite  side,  where  the  stimulus  to  contraction  is 
small,  and  where  the  protoplasm  can  extend  without  hindrance;  the  leuco- 
cyte now  moves  away  from  the  excitant,  and  there  is  negative  chemiotaxis. 
Besides  oxygen,  albuminoid  substances  (casein  of  gluten,  an  emulsion  of 
flour,  peas  and  wheat) ;  ferments  (laccase) ;  microbic  toxines,  and  the  greater 
number  of  pathogenic  microbes  or  saphrophytes,  produce  positive  chemio- 
taxis. Lubarsch  has  shown  that  living  bacteria  are  productive  of  a  posi- 
tive chemiotaxis ;  more  marked  than  that  caused  by  the  same  bacteria 
previously  heated.  From  the  researches  of  Peckelharing,  it  follows  that 
bacteria  cause  a  more  intense  chemiotaxis  than  inert  bodies  such  as  fila- 
ments of  cotton  ;  on  the  other  hand,  quinine,  jeguirity,  chloroform,  alcohol, 
glycerine,  lactic  acid,  solutions  of  salts  of  soda  and  potash  up  to  10  per 
cent.,  the  microbe  of  chicken  cholera  induce  a  negative  chemiotaxis.  In  the 
curarized  frog,  there  is  no  leucolysis  as  Drozdoff  imagined,  but  emigration 
en  masse  of  white  blood  corpuscles  into  the  lymphatic  channels  (Tarchanoff). 
Water,  weak  solutions  of  salt,  of  soda,  and  potash,  peptone,  phloridzin,  krea- 
tin,  kreatinin,  and  allantoin  do  not  provoke  chemiotaxis. 

The  sensibility  of  leucocytes  varies  according  to  the  species  of  the  ani- 
mal, and  the  age  of  the  individual.  The  leucocytes  of  mammals  appear  to 
be  more  sensitive  than  those  of  cold  blooded  animals  (Gabritchevsky) ;  and 
according  to  Borisoff,  they  are  more  sensitive  in  the  young  than  the  old. 
This  author  has  stated  that  none  of  the  substances  used  in  his  experiments 
attracted  one  variety  of  leucocyte  rather  than  another.  In  the  same  subject 
I  have  seen  the  same  microbe  provoke  leucocytic  reactions,  vanning  in 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM      25 

kind  according  to  the  organ  under  observation.  Sometimes,  on  the  contrary, 
certain  varieties  of  white  cells  are  phagocytes  to  a  certain  microbe  to  the 
exclusion  of  all  other  kinds  of  microbe.  Thus,  Metchnikoff  thinks  that  the 
polynuclear  cells  surround  the  streptocci  of  erysipelas  and  the  gonococci, 
but  this  is  not  the  case  with  the  mononuclear  cells  ;  the  latter,  however, 
surround  the  bacillus  of  Hensen,  but  this  is  not  the  case  with  the  polynu- 
clear cells.  Similarly,  in  the  experiments  of  Besredka,  it  was  the  macrocy tes 
(large  mononuclear  cells)  which  were  invariably  and  exclusively  attracted 
by  the  tersulphide  of  arsenic.  Nevertheless,  it  cannot  be  supposed  that  as  a 
general  rule  each  type  of  leucocyte  possesses  a  special  chemiotaxis.  Granted 
this  fact,  and  granted  that  the  same  leucocyte,  whether  neutrophile  or 
eosinophile,  is  attracted  by  the  most  different  kinds  of  microbes,  it  may  be 
seen  that  even  for  pure  infections,  the  qualitative  study  of  leucocytosis 
is  of  little  use  in  aiding  us  in  our  clinical  diagnosis. 

Absorption  of  solid  particles  and  typical  elements  (Phagocytosis).— 
For  a  long  time  it  has  been  known  that  leucocytes  absorb  the 
solid  amorphous  particles  of  cellular  debris.  So  long  ago  as  1862, 
Heckel  discovered  that  the  leucocytes  of  Thetys  devoured  grains  of 
indigo.  Recklinghausen,  Preyer,  Schultze  and  Balbiani  have  made 
similar  observations  on  different  objects.  Virchow,  Koelliker,  and 
Langhans  have  seen  that  blood  debris  from  old  haemorrhagic  foci 
was  carried  away  by  white  cells.  Arnold  discovered  the  presence 
of  iron,  not  only  in  protoplasm,  but  sometimes  also  in  the  nucleus  ; 
Jolly  has  seen  grains  of  starch,  depressing  the  nucleus,  whilst  others 
were  found  in  its  centre  ;  producing  an  appearance  like  that  of  two 
projections  from  the  nucleus,  joined  together  behind  the  foreign 
body  which  is  thus  incorporated. 

These  facts  ought  to  open  new  views  in  biology.     Since  leuco- 
cytes absorb  solid  particles  of  colouring  matter,  we  may  suppose 
that  they  do  the  same  for  insoluble  chemical  substances,  whether 
useful  or  detrimental.     As  a  matter  of  fact,  Besredka  has  observed 
the  phagocytosis  of  the  tersulphide  of  arsenic  ;  Arnozan,  and  Montel, 
that  of  calomel,  and  of  salicylate  of  soda ;  Landerer,  that  of  balsam 
of  Peru.     In  the  same  way,  contrary  to  the  old  dictum — corpora 
non  agunt  nisi  soluta,  we  may  imagine  that  the  organism  utilizes  in- 
soluble substances.     We  may  and  we  must  admit  that  assimilation 
takes  place  within  the  tissues  themselves,  and  outside  the  digestive 
canal.   In  a  word,  since  the  leucocytes  absorb  cellular  debris,  we  may 
suppose  that  they  may  also  be  capable  of  digesting  animal  or  vegetable 
cells  (microbian).     Since  1874,Rouget  has  observed  haematophagic 
leucocytes,  which  after  destroying  the  red  blood  corpuscles  ingested 
by  them,  changed  into  pigmentary  cells.    Metchnikoff  has  studied  the 
hist oly sis  of  the  Sponges,  Echincderms,   and  Amphibians.     In   the 


26  THE    LYMPHATICS 

same  way,  the  works  of  Kowalewsky,  and  van  Rees,  have  endea- 
voured to  show  the  importance  of  the  role  of  myophagic  leucocytes 
in  the  histolytic  phenomena  of  nymphosis.  Metchnikoff  and  his 
pupils  have  shown  that  the  white  cell  can  eat  up  the  most  diverse 
kinds  of  microbian  cells  :  this  phagocytosis  does  not  seem,  however, 
to  be  a  special  and  exclusive  property  of  the  white  cell ;  for  example, 
though  the  histolysis  of  the  tail  of  batrachians  is  attributed  to  leu- 
cocytes by  Bataillon,  it  is  attributed  to  muscular  phagocytes  by 
Metchnikoff  and  Soudakewitch;  similarly,  though  Kolesnikoff,  Weller, 
Babes,  Valenza,  Pugnat,  Franca  and  Athias  think  that  neurono- 
phagacis  is  the  work  of  leucocytes,  it  is  according  to  the  statements 
of  Krauss,  Marinesco,  Nissl,  Anglade,  and  Rispal,  caused  by  a 
neurogliac  cell.  Moreover  all  leucocytes  are  not  phagocytes  ;  the 
small  corpuscles  are  not,  and  the  eosinophiles  only  slightly  so. 

Now,  are  the  cells  absorbed  by  the  leucocytes  normal,  or  have 
they  been  previously  altered  ?  It  would  appear  that  the  answer 
is  not  the  same  for  the  animal  and  the  microbic  cell. 

In  the  case  of  the  microbic  cell,  it  seems  there  is  no  doubt  that 
it  may  be  ingested  while  alive,  because  even  when  thus  digested  ^ 
it  still  sometimes  retains  its  power  of  killing. 

In  the  case  of  the  animal  cell,  the  problem  is  more  complex,  and 

the  answer  less  easy.    As  a  matter  of  fact,  we  should  a  priori,  expect 

this  phenomenon  to  depend  either  upon   an  anomalous  exaltation 

of  cytophagic   activity  of  the  white  corpuscle,  or  upon  a  previous 

enfeeblement  of,  or  the  death  of  the  phagocytic  cell.     The  evolution 

of  the  process  is  often  so  rapid  that  histologically  it  is  very  difficult 

to  determine  the  part  played  by  these  two  factors  respectively. 

On  the   other   hand,  a  cell    may    be   functionally  weakened,   and 

diseased,  without   this    state   of    diminished  resistance   necessarily 

producing  any  morphological  change.     These  considerations  enable 

us  to  understand  all  the  discussions  which  have  been  raised  by  the 

role  played  by  phagocytes  in  the  nymphal  histolysis  of  insects  or 

in  that  of  the  tailless  batrachians :   some  maintaining  that  the  cell 

disappears  under  the  repeated  efforts    of  the  leucocytes  :   others, 

in  fact  the  majority,  asserting  that  the  white   corpuscles  confine 

themselves    to   removing   the  residue   from    an   organ    which  has 

already  been  altered.     Without  now  entering  into   this    question, 

we   will  simply   remark  that  after  studying    the   works  of   Loos, 

Eberth,    Noetzel,    etc.,   works  which   tend    to     prove     that     the 

solvent  action  of  tissue  juices  and  of  blood  is  sufficient  for  this 

destruction,  all  the  evidence  goes  to  show  that  functionally  at  least 


GENERAL    ANATOMY  OF  THE  LYMPHATIC  SYSTEM    27 

the  cells  thus  digested  are  clearly  in  a  state  of  inferiority  owing  to 
an  arrest  of  their  development,  a  considerable  diminution  or 
suspension  of  their  nutritive  changes,  etc. 

But  what  do  we  find  is  the  case  in  mammals  ?  If  we  leave  on 
one  side  those  epithelial  cells  which  are  casually  destroyed  by  the 
migration  of  white  corpuscles,  we  find  that  the  latter  attack  the 
muscular  cells  in  the  course  of  infectious  or  toxic  processes,  and 
the  red  corpuscles  in  the  case  of  the  leuchaemias.  This  liaema- 
tophagic  action  of  leuchaemic  leucocytes  allows  us  logically  to 
assume  hyperactivity  of  the  white  corpuscles,  as  well  as  a  diminu- 
tion in  resistance  of  the  red.  On  the  other  hand,  the  myophagic 
action  of  leucocytes  is  more  suggestive ;  it  shows  that  the 
muscular  fibres  are  not  digested,  unless  their  nutrition  has  pre- 
viously been  impoverished  owing  to  a  nerve  lesion  or  the  presence 
of  a  toxic  agent.  Admitting  these  facts,  and  admitting  those 
observed  in  the  physiological  atrophy  of  invertebrates  and 
batrachians,  we  shall  not  be  illogical  in  thinking  that,  if  phago- 
cytes really  do  intervene  in  the  processes  of  atrophy  in  general 
and  of  senile  atrophy  in  particular,  they  only  destroy  cells  which 
are  already  on  the  brink  of  ruin. 

Reproduction. — Leucocytes  reproduce  themselves  by  direct  divi- 
sion (amitosis)  and  by  indirect  division  (karyokinesis).  Arnold 
thinks  he  has  found  in  the  more  or  less  filamentous  arrangement 
of  chromatin  elements  in  certain  leucocytes,  a  proof  of  the  existence 
of  a  mode  of  division  which  is  intermediate  between  direct  and 
indirect  division.  But  Flemming  and  Reinke  are  of  opinion  that 
it  is  a  question  either  of  indirect  multipolar  divisions,  or  else  of 
figures  altered  by  reagents.  Leucocytes  can  divide  in  the  blood, 
the  lymph,  the  connective  tissue,  the  haematopoietic  organs,  in 
the  lymphatic  glands,  the  spleen,  and  in  the  medulla  of  bones. 

As  a  general  rule,  and  with  exceptions,  which  generally  are 
pathological,  we  may  say  that  the  more  numerous,  and  the  better 
developed  the  haematopoietic  organs,  the  less  numerous  are  the  divi- 
sions of  white  corpuscles  in  the  circulation.  For  example,  in  the  case 
of  invertebrates,  Cuenot  found  few  or  no  divisions  in  the  leucocytes 
of  cephalopods,  or  of  crustacean  decapods,  which  possess  lymphatic 
glands  ;  divisions  are,  on  the  contrary,  frequent  in  the  circulating 
white  corpuscles  of  the  pulmonates,  the  gasteropods,  the  orthoptera, 
the  araneids,  the  solifugae,  the  oligochetae,  and  leeches,  which 
have  or  appear  to  have  no  lymphatic  organs. 

There  are  exceptions  :  thus  the  lamellibranchs  possess  lymphatic 


28  THE    LYMPHATICS 

glands,  and  though  Apathy,  de  Bruyne,  and  Cuenot  have  seen 
mitoses :  Knoll,  Owsjannikow  and  Carazzi  have  seen  amitoses  on 
their  free  corpuscles.  Similarly,  among  the  vertebrates,  and  even 
in  the  mammals,  where  however  the  haematopoietic  centres  take 
on  at  certain  times  such  an  extraordinary  development,  it  is  possible 
to  observe  the  division  of  white  corpuscles  wandering  in  the  blood, 
the  lymph,  the  connective  tissue,  and  foreign  bodies  (pith  of  elder). 

In  the  blood,  we  may  find  mitoses,  or  direct  division.  It  was  in 
the  blood  of  the  axolotl  that  Ranvier  observed  the  direct  division 
of  leucocytes  ;  and  in  the  blood  of  the  same  animal  that  Lavdovsky 
found  mitoses.  Hemming  doubts  the  accuracy  of  the  observations 
of  this  latter  author.  Klein  and  Lowit  have  observed  divisions 
in  the  blood  of  the  triton. 

Mitoses  have  been  noticed  in  the  blood  of  the  dog,  rabbit,  human 
embryo,  and  infant  by  Kultchitsky,  Spronck  and  Prins,  Wertheim, 
Hock  and  Schlesinger.  Roehmer  also  admits  the  possibility  of  the 
reproduction  of  leucocytes  in  the  blood  by  one  or  other  of  the 
two  modes  of  division  ;  again,  this  reproduction  in  the  blood  is 
admitted  by  MedwedeiT  and  Markewitsch  :  Wlaeff  has  observed  it 
after  splenectomy,  and  numerous  authors  have  noticed  it  in 
leuchaemic  blood. 

Gourevitch  has  seen  karyokinesis  in  the  blood  after  injection  of 
abrin,  and  of  ricin,  substances  which  at  first  provoke  hypoleuco- 
cytosis,  and  then  hyperleucoc37tosis. 

In  the  lymph  of  the  thoracic  duct,  Lowit  has  observed  mitosis  ; 
I  have  observed  numerous  mitoses  in  leucocytes  circulating  in  the 
cavernous  spaces  of  the  mesenteric  gland  of  a  rabbit  into  whose 
veins  I  had  injected  pilocarpin.  The  chromosomes  of  some  of  the 
white  corpuscles  were  arranged  in  the  shape  of  a  crown  ;  which 
arrangement  has  also  been  observed  by  Kostanecki.  Meves  and 
Henneguy  have  shown  that  this  arrangement  was  due  to  the  per- 
sistence of  the  sphere  of  attraction  at  the  centre  of  the  figure,  and 
that  in  the  Salamander,  it  involved  the  formation  of  the  annular 
or  perforated  nucleus  of  the  spermatogens.  We  may  suppose  that 
certain  annular  nuclei  of  leucocytes  have  a  similar  origin. 

In  the  cerebrospinal  fluid  from  a  case  of  general  paralysis,  I  have 
seen  the  direct  division  of  the  nucleus  of  some  small  white  cor- 
puscles which  possessed  no  granules. 

In  the  peritoneal  serous  fluid  of  Lacerta  viridis,  Jolly  has  noticed 
mitoses.  Peremeschko,  Kultchitsky,  Muskabluth,  Metchnikoff, 
Flemming,  Giovannini,  Dekhuysen,  Van  der  Stricht,  Denys,  and 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM  29 

M.  Heidenhain  have  described  the  mitoses  of  wandering  cells  of 
connective  tissue  ;  Arnold  and  Marchand  those  of  leucocytes  which 
had  migrated  into  a  fragment  of  the  pith  of  elder  (?).  The 
mitoses  observed  by  Heidenhain  and  du  Bruyne,  in  the  white 
corpuscles  which  infiltrate  the  intestinal  epithelium,  are  not  ad- 
mitted by  Nicolas.  In  the  normal  state,  in  mammals,  the  repro- 
duction of  free  white  corpuscles  appears  then  quite  certain ;  but  as 
regards  the  blood  it  does  not  appear  to  be  so  frequent  as  certain 
writers  would  have  us  believe.  As  a  matter  of  fact,  Spronck  and 
Prins  counted  18  mitoses  in  9653  leucocytes  in  sections  of  the 
vena  cava  of  the  rabbit,  and  2  mitoses  in  1901  leucocytes  of 
human  blood  obtained  by  digital  puncture.  Now  Lowit  counted 
5000  white  corpuscles  without  rinding  a  single  kinesis.  This  author 
maintained  that  leucoblasts  always  divided  directly  ;  and  the  erytho- 
blasts  indirectly ;  but  Denis  and  Van  der  Stricht  have  proved  the 
reality  of  the  mitosis  of  leucoblasts. 

It  was  also  believed  that  the  polynuclear  cells  divided  directly ; 
and  the  mononuclears,  indirectly.  It  is  now,  however,  demonstrated 
that  the  polynuclears,  like  the  eosinophiles,  show  karyokinesis. 
The  one  or  the  other  mode  of  division  should  not  therefore  be 
regarded  as  the  exclusive  property  of  any  particular  variety  of 
leucocyte. 

On  the  other  hand,  amitosis  seems,  if  not  to  exist  exclusively, 
at  any  rate  to  predominate  largely  in  the  pulmonates,  oligochetae, 
and  leeches ;  while  kinesis  predominates  in  the  orthopterae 
(Heidenhain),  and  in  the  solifugae.  Again,  amitosis  seems  to  be 
more  frequent  in  the  axolotl  than  among  mammals. 

There  is  no  object  in  here  describing  the  karyokinesis  of  leuco- 
cytes, which  in  general,  presents  no  special  features.  Let  us  con- 
fine ourselves  to  remembering  the  possibility  of  anomalous 
kineses ;  those  in  which  the  chromosomes  are  arranged  in  the 
form  of  a  crown  about  the  centrosome,  and  which  produce  certain 
perforated  nuclei ;  those  with  multiple  poles  which,  unaccompanied 
by  protoplasmic  division,  give  rise  to  multinuclear  cells.  Van 
der  Stricht,  who  like  Heidenhain,  does  not  admit  any  connexion 
between  the  polymorphism  of  the  nucleus,  and  its  direct  division, 
thinks  with  van  Bambeke  and  Kostanechi,  that  certain  poly- 
morphous nuclei  result  from  the  fusion  of  several  smaller  nuclei. 

The  amitosis  of  leucocytes,  described  by  Ranvier,  Bizzozero,  and 
Arnold,  will  engage  our  attention  longer.  Ranvier  has  stated  that  at  a 
temperature  of  16°  a  white  corpuscle  of  axolotl  requires  three  hours 


30  THE    LYMPHATICS 

for  its  direct  division.     In  ordinary  direct  division,  the  nucleus  is 
seen  to  divide  into  two  segments   or  buds,   of  nearly   equal  size, 
bound  by  a  pedicle  which,  becoming  thinner  and  thinner,    finally 
breaks.      The  division  of  the  protoplasm  soon  follows  that  of  the 
nucleus.     It  is  quite  evident  that  if  the  division  of  the  protoplasm 
does  not  take  place,   there  results   a   multinuclear   cell  (Arnold). 
It  also  happens  that  the  buds  do  not  detach  themselves  or  fuse 
again  (Ranvier).     When  the  nucleus   divides   directly  into   several 
unequal  fragments,    we  can  witness    the    process  which  has  been 
described  by  Arnold  under  the    name   of   fragmentation.      Arnold 
thought  that  some  relation  might  exist  between  this  fragmentation 
and  the  production  of  certain  perforated  nuclei.     Goeppert  thought 
that  the  perforation  of  the  nucleus  was  a  secondary  phenomenon,  and 
resulted  from  an  invagination  of  the  wall  which  deepened  until  it 
reached    the    opposite    surface    of    the    nuclear    membrane.      The 
annular  nuclei,  he  thought,  divided  directly  by  constriction  into  two 
half  rings  which  afterwards  separated  into  many  fragments,  again 
by  constriction.    We  may  inquire  what  becomes  of  the  centrosomes 
in  direct  division  ?  Flemming,  stating  that  in  the  leucocytes  of  the 
salamander,  the  centrosome  does  not  divide  into  two,  thinks  that 
the  attraction  sphere  exercises  an  influence  upon  this  division,  for 
it  is  always  placed  opposite  to  the  line  of  separation  of  the  two 
portions  of  the  nucleus. 

What  is  the  significance  of  the  amitosis  of  Ieucoc3^tes  ?  Flemming 
thinks  it  is  a  phenomenon  of  degeneration  which,  most  frequently, 
increases  the  surface  of  the  nucleus  while  producing  multinuclear 
cells.  Zieyler  and  von  Rath  express  an  almost  analogous  opinion  : 
namely,  that  when  direct  division  takes  place  both  in  the  nucleus 
and  protoplasm,  the  daughter  cells  cannot  subsequently  divide. 
Lowit,  on  the  contrary,  is  of  opinion  that  by  the  side  of  this  direct 
degenerative  division,  there  is  a  direct  regenerative  division,  follow- 
ing which  cells  may  continue  to  multiply.  This  histologist  is  of 
opinion  that  the  richness  of  the  nucleus  in  pyrenin  or  chromatin  is 
variable ; — a  nucleus  rich  in  pyrenin  divides  directly,  a  nucleus 
rich  in  chromatin  indirectly.  Henneguy  thinks  that  nuclei  which 
divide  directly  are  no  richer  in  pyrenin  than  in  chromatin. 

Evolution,  Degeneration,  and  Death. — Of  the  ancestral  protoplasms 
with  free  and  independent  life,  the  leucocytes  have  preserved,  in 
spite  of  adaptations  necessary  to  new  conditions  of  existence  in 
cellular  colonies,  not  only  their  sensitiveness,  their  motility,  their 
powers  of  digestion  and  reproduction,  but  even  their  individuality, 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM     31 

and  their  remarkable  resistance  to  destructive  agencies.  Twenty-four 
hours  after  the  death  of  the  human  body,  the  greater  number  of 
leucocytes  are  still  living  and  can,  under  favourable  conditions,  keep 
alive  much  longer  (Verworn).  Recklinghausen  and  Ranvier  have 
shewn  that  they  are  capable  of  retaining  their  properties  outside 
the  organism,  sometimes  for  a  very  long  period,  viz.  22  days. 

It  is  difficult  to  know,  even  approximately,  the  duration  of  the 
normal  life  of  a  leucocyte.  Everard,  Massart  and  Demoor  suppose 
it  to  be  very  short.  Yet  it  may  be  fairly  long,  at  least  in  the  case  of 
the  aged.  As  the  white  corpuscles  in  the  case  of  the  aged  do  not 
appear  to  divide  in  the  blood,  or  in  the  atrophic  haematopoietic 
organs,  Ave  may  admit,  if  not  their  permanence,  at  least  their  power 
of  living  a  more  or  less 
long  life. 

Nevertheless,  either 
spontaneously  or 
u  n  d  e  r  d  i  ff  e  r  e  n  t 
physical  or  chemical 
influences,  leucocytes 

may     degenerate     and      -  £%\         /?©)         \&b}       ( ( )1 
die.     The  degenerative     {^J 

changes  are  numerous.  *"IG-  3. — Degeneration  of  leucocytes  :  hyperchromasis 
T  £  ,  and  fragmentation  of  nucleus  (chromolysis) ;  vacuoliza- 

111    SOme     Ot    the     aiiae-    t ion  and  hypochromasis  of  nucleus. 

mias,  Hayem  mentions 

the  surcharge  of  haemoglobin  from  certain  mononuclears  ;  other 
cells  become  infiltrated  with  fat,  glycogen  and  pigments  (see 
Chemical  Constitution).  Czerny  and  Grigorjeff  think  the  leu- 
cocytes may  become  infiltrated  with  amyloid  material ;  but  this 
fact  is  contradicted  by  Obrzut.  Ziegler  describes  a  mucoid  degen- 
eration of  these  elements. 

Heidenhain,  Arnold,  and  Gunprecht  have  studied  the  chromolytic 
degeneration  of  leucocytes.  The  chromatin  network  becomes  con- 
densed, forming  a  compact  and  homogeneous  mass  which  breaks 
into  fragments  :  balls  are  thus  formed  which,  after  the  rupture  of 
the  nuclear  membrane  are  scattered  throughout  the  protoplasm  ; 
the  latter  after  swelling  up  and  becoming  vacuolated  finally  dis- 
appears, dissolved  in  the  surrounding  liquids.  The  nucleus  thus 
altered  is  at  first  more  readily  stained  than  in  the  normal  state, 
elsewhere  it  is  pale,  and  its  contour  ill-defined.  This  last  form  of 
degeneration,  described  by  Klein  under  the  name  of  "  leucocyte 
shadow,"  is  perhaps  artificial.  Ranvier  questions  if  leucocytes 


32  THE    LYMPHATICS 

which  are  destroyed  at  the  site  of  a  lesion  during  the  process  of 
repair,  do  not  thus  furnish  nutritive  material  to  the  tissues  during 
the  process  of  rebuilding.  T.  Botkine,  Engel,  Borissoff  and  Kheta- 
gouroff  have  studied  the  histolysis  of  the  leucocytes  in  blood.  Bot- 
kine has  even  supposed  that  many  of  the  varieties  of  leucocytes  met 
with  are  only  different  stages  of  their  disintegration  in  the  plasma. 
In  addition  to  this  total  histolysis  there  is  a  partial  destruction 
by  means  of  which  the  white  corpuscle  causes  the  disintegration  of 
some  of  its  granules  or  a  portion  of  its  protoplasm  :  this  physiolog- 
ical degeneration  has  been  described  by  Ranvier  under  the  name  of 
clasmatosis,  and  is  regarded  by  him  as  a  kind  of  secretion.  Other 
leucocytes  perish  in  this  manner  owing  to  a  kind  of  continual  wear  of 
parts  of  their  protoplasm  against  each  other.  Jolly  thinks  that,  fre- 
quently eosinophile  granules  which  have  been  suddenly  separated 
from  each  other,  and  scattered  over  a  fairly  large  surface  (Klein)  can 
join  together  again  ;  in  such  cases  there  would  be  an  appearance  of, 
but  not  a  true  destruction  of  the  leucocyte.  In  all  protoplasmic 
elements,  in  the  Rhizopods  for  example,  white  corpuscles  always  die 
when  they  contract,  that  is  to  say  when  they  assume  a  nearly  spherical 
form.  During  the  process  of  decomposition  of  the  protoplasm,  pale 
expansions  shoot  out  which  festoon  its  borders  :  these  excrescences 
become  detached  in  the  form  of  clear,  homogeneous,  smooth  balls 
(balls  or  sarcodic  excrescences  of  Dujardin)  and  disappear  without 
ever  again  returning  to  the  cellular  body.  This  process  must  not 
be  confused  with  the  formation  of  pseudopods. 

Leucocytes,  when  destroyed  by  physical  agents  (electricity,  heat) 
assume  a  round  form.  Amongst  chemical  substances,  water  and 
acetic  acid  attack  their  nucleus,  then  cause  the  protoplasm  to 
swell,  and  eventually  kills  them.  Carbonic  acid  gas  makes  them 
lose  all  their  staining  qualities  ( Yegorovski).  The  bases  (ammonia, 
soda,  and  potassium)  cause  the  nucleus  to  disappear,  and  little 
protoplasmic  vacuoles  to  appear. 

Iodine  destroys  them,  and  colours  them  a  greenish  yellow  :  it 
causes  the  appearance  of  colourless  or  slightly  violet  sarcodic 
excrescences. 

Peptone  does  not  destroy  (Tchistovitsch  and  Schultze),  but  dis- 
solves them  (Botkine,  Delezenne). 

II.     THE  DIFFERENT  LEUCOCYTES 

There  are  numerous  classifications  of  leucocytes.  We  will  recog- 
nize the  following  varieties  : — 


GENERAL    ANATOMY  OF  THE  LYMPHATIC  SYSTEM     33 

(1)  Microcytes  (lymphocytes  of  Einhorn,  Ehrlich). 

(2)  Macrocytes  (large  mononuclears). 

(3)  Cells  with  neutrophile  granules  (neutrophile  cells). 

(4)  Cells  with  acidophile  granules  (eosinophile  cells). 

(5)  Cells  with  metachromatic  basophile  granules  (cells  of   Ehrlich). 
Before  approaching  the  study  of  each  of  these  varieties  it  is 

essential  to  point  out  the  different  classifications  which  have  been 
proposed.  From  their  study  and  criticism,  we  shall  justify  the 
nomenclature  Avhich  we  suggest. 

HISTORICAL  SKETCH  OF  THE  CLASSIFICATIONS. — Leuwenhoek  (1722),  Delia 
Tore  (1776),  and  Mascagni  (1780),  saw  rounded  corpuscles  in  the  lymph.  In 
1770,  Hewson  discovered  leucocytes  in  the  blood,  and  some  time  afterwards 
Reeklinghausen,  the  migratory  cells  in  the  connective  tissue.  Several  j-ears 
were  to  elapse  before  the  attention  of  histologists  was  drawn  to  the  different 
varieties  of  white  corpuscles.  It  was  in  1845  and  1846  that  Virchow,  when 
studying  leuchaemic  blood,  distinguished  two  kinds  of  leucocytes  ;  one, 
the  more  numerous,  were  large  ;  others  were  small  and  almost  with- 
out protoplasm.  He  inquired  into  the  signification  of  these  different  cells  : 
at  first  he  thought  that  they  were  separate  elements  with  different  origins. 
Later  on  he  came  to  the  conclusion  that  they  represented  evolutionary  and 
functional  stages  of  the  same  element.  Since  then,  experiments  have  multi- 
plied, methods  have  been  perfected,  and  theories  freely  advanced,  but  the 
problem  proposed  long  ago  by  the  author  of  Cellular  Pathology  has  not 
yet  been  definitely  solved.  In  1846  Wharton  Jones  recognized  that  amongst 
leucocytes,  some  were  granular,  and  others  were  not.  This  observation 
has  retained  its  importance  in  contemporary  classifications,  all  of  which 
under  different  titles,  are  based  upon  the  very  complete  work  of  Max 
Schultze  in  1865.  In  taking  as  a  basis  for  classification  their  dimensions,  the 
shape  of  their  nucleus,  the  presence  of  granules,  this  histologist  distinguished 
four  kinds  of  leucocytes,  which  he  called  1,  2,  3  and  4  varieties.  The  first 
variety  comprises  cells  which  are  smaller  than  red  blood  corpuscles,  and 
which  are  almost  destitute  of  protoplasm;  the  second,  larger  cells,  with 
more  abundant  protoplasm,  and  a  rounded  nucleus  ;  the  third,  more 
numerous  cells,  with  very  finely  granular  protoplasm,  with  a  single  or 
multiple  nucleus;  the  fourth,  cells  with  coarse  refracting  granules:  thus 
with  the  exception  of  the  cells  of  Ehrlich,  Max  Schultze  recognized 
.all  the  varieties  of  leucocytes.  Hayem's  classification  is  very  similar  to  that 
of  Max  Schultze,  but  a  new  observation  was  however  made,  for  the  French 
haematologist  described  two  kinds  of  non-granular  cells  :  one  having  clear 
protoplasm,  the  other,  opaque  coloured  protoplasm.  The  old  histologists,  as 
may  be  seen,  refrained  from  giving  names  to  cells  which  they  studied,  but 
this  reserve  has  not  been  observed  by  their  successors.  These  names  are 
either  in  accordance  witli  the  dimensions  of  the  cell,  the  form  of  the  nucleus, 
•the  nature  of  the  granules,  or  in  accordance  with  the  presumed  origin,  or 
probable  age  of  the  white  cell ;  sometimes  again  the  names  given  suggest  one 
of  its  physiological  properties.  Compromises  have  been  established  between 
terminologies  founded  on  these  different  principles,  and  it  may  be  said  that 
the  extreme  difficulty  of  reading  books  of  haematology  is  the  least  of  the 
inconveniences  caused  by  this  system  of  nomenclature. 


34  THE    LYMPHATICS 

According  to  their  dimensions  and  the  shape  of  their  nuclei,  Lb'wit  dis- 
tinguishes amongst  the  white  corpuscles  : — 

1.  small  mononuclears. 

2.  large  mononuclears. 

3.  leucocytes  with  polymorphous  nuclei. 

4.  polynuclears. 

This  terminology,  which  is  still  largely  used  to-day,  has  been  the  subject  of 
criticisms,  both  numerous  and  well  founded.  Ranvier,  Flemming,  and 
Heidenhain.  having  shown  that  the  leucocyte  called  poly  nuclear  was  almost 
always  a  cell  with  a  polymorphous  nucleus,  it  became  necessary  to  proscribe 
the  term  as  being  inaccurate,  though  unfortunately  it  is  still  sanctioned  by 
usage.  Again,  as  Metclmikoff  has  observed,  it  is  just  those  cells  which  are 
called  large  mononuclears  which  as  a  matter  of  fact  sometimes  have  two  or 
three  perfectly  distinct  nuclei.  This  scientist  has  given  the  name  of 
macro  phages  to  these  large  mononuclears,  a  name  which  while  it  involves  no 
theories  as  to  their  origin,  or  the  necessarily  variable  appearance  of  their 
nuclei,  has  the  advantage  of  reminding  us  of  their  size,  and  their  re- 
markable phagocytic  properties.  The  other  leucocytes  (eosinophiles,  cells 
with  neutrophile  granules)  are  called  micro phages.  Such  a  terminology  is 
not  without  inconvenience  from  the  histological  point  of  view  ;  for  it  in- 
cludes under  the  generic  term  of  macrophage,  elements  of  widely  different 
origin  and  significance,  viz.,  leucocj'tes,  eiidothelial  cells,  neurogliac,  and 
nervous  cells.  Neither  does  it  do  away  with  the  necessity  for  using  other 
terms  to  denote  the  different  microphages,  and  for  those  white  corpuscles 
which  are  not  phagocytic. 

Ouskoff  classifies  leucocytes  as  young,  mature,  and  old  according  to 
their  age.  The  young  are  the  small  and  large  lymphocytes,  and  the  small 
transparent  corpuscles.  The  mature  are  the  large  and  lobulated  transparent 
corpuscles,  and  the  transitional  forms,  small,  large,  and  lobulated.  The  old  the 
mononuclears,  and  the  polynuclears.  In  this  system  the  eosinophiles  are 
not  included  in  any  of  the  divisions  established  by  the  Russian  histologist. 

It  is  quite  clear  that  the  small  mononuclears  much  resemble  young  cells 
and  even  embryonic  cells.  It  is  more  difficult  to  admit  the  senility  of  the  large 
mononuclears;  and  of  the  polynuclears ;  their  amoebic  and  their  phagocytic 
properties  afford  too  much  evidence  of  their  powerful  vitality. 

Ehrlich  describes  six  normal  kinds  of  leucocytes — 

( 1 )  Lymphocytes. 

(2)  Large  mononuclears. 

(3)  Transitional  forms. 

(4)  Polynuclears. 

(5)  Eosinophiles. 

(6)  "  Crammed  cells"  (Metclmikoff  thus  translates  the  expression,  "  Mas- 
tzelleii";    they  are  also  called  "fattened  cells."      "  Stuffed  cells  "  is  perhaps 
more  accurate. 

In  addition  Ehrlich  admits  four  anomalous  forms. 

(1)  Neutrophile  mononuclears  (neutrophile  myelocytes). 

(2)  Small  neutrophile  pseudo-lymphocytes. 

(3)  Eosinophile  mononuclears  (eosinophile  myelocytes). 

(4)  Irritation  form  of  Tiirck. 

It  will  be  seen  apart  from  the  term  lymphocyte  (Einhorn),  that  Ehrlich, 
retains  the  terminology  based  on  the  appearance  of  the  nucleus  :  but  now 
that  it  is  recognized  that  the  lymphocyte  is  found  not  only  in  lymphoid 
organs  (glands  and  spleen),  but  also  in  the  marrow  of  bones  (Dominici,  Pap- 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM    35 

penheim)  it  seems  that  there  is  no  advantage  in  substituting  this  term  for 
that  of  small  mononuclears.  The  transitional  form  may  perhaps  be  described 
with  the  large  mononuclear.  And  since  the  irritation  form  of  Tiirck 
appears  to  represent  a  nucleated  red  blood  corpuscle  (Ehrlich,  Engel),  it  is 
useless  to  retain  the  term  here.  The  existence  of  this  cell  will  suffice  to 
prove  how  delicate  is  the  distinction  between  a  white  and  a  red  cell. 

Though  the  eosinophile  mononuclears  constitute  abnormal  elements  in 
human  blood,  they  are  constant  in  the  blood  of  the  pig  and  in  that  of  the  horse. 
They  cannot  be  called  eosinophile  myelocytes  seeing  that  they  are  some- 
times formed  in  the  lymphatic  glands  and  in  the  thymus. 

Notwithstanding    its    clearness,     there   are    a   great   many   objections   to 
Denys's    classification.         This    author  lays    down     that   all     non-granular 
leucocj^tes  are  derived  from    lymphoid    tissue  ;    he    mixes  them   up  under 
the    name    of    lymphocytes.        All    the    granular    leucocytes    ccming    from 
the  marrow  of  bone,  are  called  myelocytes.     Whatever  may  be  the  dimensions 
and  shape  of  their  nuclei,  these  myelocytes  are  acidophile,  basophile,  neutro- 
phile,  according  to  the  nature  of  their  granules.     It  is  unfortunate  that  the 
brilliant  simplicity  of  this  conception  accords  so  ill  with    the  facts.     First 
of  all  it  takes  for  granted,  what  is  far  from  being  demonstrated,  namely  that 
leucocytes  cannot  originate  except  from  bony  marrow  or  lymphoid   struc- 
tures, and  it  does  not  even  refer  to  the  possibility  of  their  origin  from  connective 
tissue.    Now  the  white  corpuscles  are  very  constant  formations  in  the  animal 
series,  and  in  the  aged,  and  we  might  almost  say,  commonly  found  in  all  many- 
celled  beings.     In  phylogenesis  as  in  ontogenesis,  they  exist  before  the  appear- 
ance   of    the    haematopoietic    organs.      Whether  they  are    of    mesoblastic 
or  entodermic  (vascular  endothelium)  origin,  some  of  them  bear  a  strange 
resemblance  to  the  fixed  elements  in  connective  tissue.     These  resemblances 
are  such  that  even  now  there  is  much  discussion  as  to  whether  the  plasmatic 
cell  of  Waldeyer,  and  Unna,  arises  from  connective  tissue  or  from  leucocytes. 
Whilst  Unna,  Menahem  and  Hodara  uphold  the  connective  tissue  origin  ;  Jados- 
sohn,  Marshalko  and  Dominici  support  the  leucocyte  origin  (lymphocyte).     On 
the  other  hand,  the  cells  of  Ehrlich  (the  fattened  cells),  which  have  been  separa- 
ted from  the  group  of  plasmatic  cells  on  account  of  their  metachromatic  gran- 
ules, are  often  more  numerous  in  the  connective  tissue  of  viscera  than  in  bonv 
marrow.  Moreover,  in  the  fin  of  the  tadpole,  Metchnikoff  has  observed  all  transi- 
tions between  the  connective  tissue  cell  and  the  white  cell.   Further,  knowing 
that  the  fixed  cells  are  not  phagocytic  and  finding  foreign  substances  within 
some  of  them,  MetchnikofT  concluded  that  the  latter  were  old  phagocytes  which 
had  become  fixed.     Finally,  the  splendid  researches  of  Ranvier  have  shown 
that  the  clasmatocytes  are  fixed  leucocytes,  capable  of  movement.     It  is  there- 
fore quite  certain  that  there  is  an  intimate  analogy  between  the  connective 
tissue  cell  and  the  white  cell  ;    it   is  proved  that  a  leucocyte  can  become  a 
connective  tissue  cell,  and  it  is  at  least  very  probable  that  a  connective  tissue 
cell  can  become  a  white  cell.     The  majority  of  anatomo-pathologists  admit 
that  the  embryonic  connective  tissue  cell,  which  morphologically  so  resembles 
a  young  leucocyte  is  capable  of  movement,  and  therefore  of  physiologically 
resembling  it. 

Numerous  observers  having  seen  wandering  leucocytes  divide  in  the  con- 
nective tissue  meshes,  it  is  certain  that  these  elements  can  reproduce  them- 
selves elsewhere  than  in  the  large  lympho-medullary  centres. 

Leucopoiesis,  like  haematopoiesis,  appears  to  be  an  elaboration  of  many 
stages,  varying  according  to  the  zoological  species,  and  probably  according 
to  the  age  of  the  individual. 


36  THE    LYMPHATICS 

If  we  admit  the  lympho-medullary  centres  to  be  the  sole  sources  of  origin, 
and  yet  reject  as  improbable,  the  permanence  or  the  reproduction  of  free  ele- 
ments in  the  blood  plasma,  the  lymphatic,  or  the  connective  tissue  systems  ; 
then  it  is  very  difficult  to  understand  how  blood  renovations  take  place  in  the 
aged.  A  definite  though  intermittent  leucopoiesis  of  connective  tissue  origin 
would  perhaps  furnish  a  more  satisfactory  explanation  of  this  phenomenon. 
We  may  now  incjuire  what  objections  can  be  raised  to  the  theory  which, 
while  it  distinguishes  two  kinds  of  leucocytes,  places  the  origin  of  some  in  the 
marrow,  of  others  in  the  gland.  This  theory  takes  for  granted  that  the 
various  leucocytes  bear  no  relation  to  each  other  :  a  point  on  which  there 
has  been  much  controversy. 

Though  it  is  not  certain  that  transitional  forms  between  the  various 
granules  exist  ;  and  though  in  the  blood  and  lymph  forms  of  transition 
between  the  granular  and  non-granular  cells  are  few  in  number,  and  not 
sharply  marked,  the  case  is  other  with  the  haematopoietic  organs.  Here  it 
is  both  possible  and  easy  to  see  the  white  cell  acquire  granules. 

Now  while  the  bony  marrow  normally  possesses  non-granular  cells  which, 
whether  small  or  large,  are  identical  with  those  of  the  tymphatic  gland, 
the  latter  can  present  in  the  normal  state  all  the  granular  cells  which 
are  regarded  as  belonging  exclusively  to  the  bony  marrow.  But  it  has 
been  argued,  the  presence  of  cells  in  the  gland  does  not  necessarily  mean 
their  production  there  :  these  wandering  elements,  which  are  produced  else- 
where, become  fixed  there  by  unknown  influences.  It  must  be  admitted  that 
this  objection  may  be  raised  against  those  authors  who  maintain  that  the 
marrow  is  the  site  for  the  formation  of  eosinophiles,  and  of  the  cells  loaded 
with  fat,  cells  which  are  far  from  presenting  numerous  mitoses  in  it. 

But  eosinophiles  exist  in  lymph  ;  and  sometimes,  even  in  the  gland  itself,  they 
show  indisputable  signs  of  cytodieresis  ;  sometimes  again  they  possess  but 
one  nucleus,  and  a  few  granules.  Finally  their  numbers  increase  in  pathological 
hypertrophies  or  diseases  of  the  lymphatic  gland,  in  lymphaclenoma,  and 
after  splenectomy.  It  is  very  possible  that  this  last  mentioned  eosinophile 
springs  not  only  from  the  gland,  but  also  from  the  marrow.  The  latter  is  then 
hyperactive.  The  substitution  of  the  spleen  by  an  antagonistic  organ, 
is  not  easily  intelligible,  but  it  becomes  so,  if  we  assume  that  the 
marrow,  the  spleen  and  the  glands  are  structures  which  were 
originally  identical,  differing  more  in  appearance  than  in  reality,  and 
always  ready  to  manifest  their  former  energies.  We  know  that  in  certain 
animals  a  single  organ  is  quite  sufficient  to  perform  the  duties  which  normally 
fall  upon  the  marrow,  the  spleen  and  glands.  A  long  time  ago,  Renaut  and 
Metchnikoff  observed  that  cyclostomes  removed  from  the  marrow  of  bones 
possessed  eosinophiles.  On  the  other  hand,  the  aged  in  spite  of  the  func- 
tional disappearance  of  the  marrow,  which  has  long  since  been  invaded 
by  fat,  possess  both  eosinophiles  and  neutrophiles.  How  can  we  term 
myelocytes,  cells  which  pre-exist  and  survive  the  organ  considered 
as  their  only  source  of  origin  ?  How  can  we  call  lymphocytes,  cells  which 
exist  in  the  marrow  as  well  as  in  the  spleen,  or  gland  ?  In  reality, 
even  in  the  higher  vertebrates,  both  the  marrow  and  the  gland  preserve 
the  imprint  of  their  original  fusion :  there  is  no  cell  called  myeloid 
which  cannot  exist  in  lymphoid  organs,  and  inversely  ;  on  the  contrary,  many 
morbid  influences  can  satisfactorily  show  this  symbiosm  of  two  lympho- 
medullary  formations,  a  symbiosm  which  is  also  well  proved  by  normal  and 
comparative  histology.  Dominici  has  related  many  cases  of  this  nature,  and 
has  grouped  them  under  the  name  of  myeloid  transformation  of  the  spleen. 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM     37 

If  for  all  these  reasons  we  find  we  have  to  sacrifice  the  terms, 
lymphocytes  and  myelocytes,  it  is  well  to  remember  that  Denys  is  quite 
right  in  not  making  the  form  of  the  nucleus  the  basis  of  his  classification, 
but  simply  classifying  the  granular  cells  according  to  the  nature  of  their 
granules. 

Without  repeating  all  the  drawbacks  of  L6 wit's  terminology,  we  may 
remark  again  that  the  shape  of  the  nucleus  represents  a  functional  state, 
which  in  the  most  various  kinds  of  cells  is  sometimes  identical,  and  in  a  differ- 
ent way  represents  the  distinctive  sign  of  a  definite  cell  species.  In  other 
words,  cells  of  the  same  species,  the  eosinophiles  for  example,  present  different 
nuclei  (single  or  double)  according  to  the  animal  considered,  and  according 
to  the  part  from  which  they  are  taken,  etc.  ;  inversely,  cells  which  vary  in 
size,  physiological  properties,  such  as  the  lymphocytes  and  the  large 
mononuclears  of  Ehrlich,  each  have  a  single  rounded  nucleus. 


Microcytes 

Synonyms. — First  variety  of  Max  Schultze,  globulins,  free  nuclei  of  Robin  ; 
nuclei  of  origin  of  Pouchet ;  lymphocytes  of  Einhorn  and  of  Ehrlich  ;  small 
clear  and  opaque  mononuclears  of  Hayem  ;  young  leucocytes  of  Ouskoff  ; 
small  lymphatic  corpuscles  of  Engel  :  leucoblasts,  primary  leucocytes, 
small  lymphocytes  of  Denys  ;  small  hyaline  cells  of  Gulland. 

These  are  cells  whose    dimensions  are  equal  to,  or  smaller,  or 
slightly  larger  than  those  of  red  blood  corpuscles  ;  the  diameter  of 
the  smallest  is  from  5' 5  /JL  to  6  /z  ;  that  of  the  largest  (the  medium- 
sized    mononuclears     of 
Malassez)  varies  between 
7"5  ;/,  and  8  JJL.      It  is  al- 
most   impossible    to  ac- 
curately   fix   the    higher 
limit  because,  as  regards 
size,    we   find    all    inter- 
mediate sizes    exist    be- 
tween the  leucocytes  and 
the  macrocytes. 

Rounded,  oval,  and  sometimes  polygonous,  these  elements  possess 
a  relatively  large  central  nucleus,  partly  surrounded  by  a  fine 
protoplasmic  border,  which  it  is  frequently  very  difficult  to  see  ;  this 
had  escaped  the  observation  of  certain  histologists  who  described 
these  elements  as  free  nuclei.  The  protoplasm  is,  proportion- 
ately to  the  nucleus,  much  more  developed  in  the  medium-sized 
elements  (the  medium-sized  mononuclears  of  Malassez).  This  layer 
of  protoplasm  is  somewhat  irregular,  and  presents  thickenings 
shaped  like  a  cap  ;  its  external  surface  often  bristles  with  points, 
or  with  detachable  buds.  The  protoplasm  is  more  refracting  than 

D 


FIG.  4. — Microcytes  and  Macrocytes. 


38  THE    LYMPHATICS 

the  nucleus.  At  one  time  it  is  like  mother-of-pearl,  colourless  or 
light,  at  another  opaque  or  coloured  (Hayem).  It  may,  on  the  other 
hand,  appear  homogeneous  or  very  finely  granular.  (We  are  now 
dealing  with  cytoplasmic  granules  which  have  probably  no  con- 
nexion with  the  granules  of  leucocytes  properly  so  called.)  It 
has  an  alkaline  reaction  (Ehrlich).  It  maybe  (1)  faintly  stained, 
or  slightly  basophile ;  or,  (2)  strongly  basophile,  more  so  even 
than  the  nucleus.  According  to  Hayem,  the  protoplasm  of  the 
small  opaque  mononuclears  of  human  blood  can  be  indiscriminately 
stained  :  it  takes  an  intense  stain  with  eosin  or  orange ;  it  turns 
a  greenish  tint  with  methylene  blue,  and  purple  with  thionin. 
Elsewhere,  the  same  author  states  that  the  opaque  mononu- 
clears in  horse's  lymph  are  especially  basophile.  The  nucleus  is 
rounded ;  and  may  present,  especially  in  the  largest  forms,  a  lateral 
depression  (Ehrlich) ;  when  this  indentation  increases,  the  nucleus 
becomes  polymorphous. 

After  fixation  by  heat,  and  staining  with  the  triacid,  the  nucleus 
appears  almost  homogeneous,  greenish  or  bluish  black  (Engel).  By 
means  of  other  fixing  agents,  we  can  distinguish  the  presence  of 
granules,  or  masses  of  chromatin  in  the  centre  or  in  the  periphery  ; 
the  central  chromatin  either  appears  elongated,or  looks  like  a  rounded 
corpuscle  :  the  peripherally  placed  chromatin  forms  a  nuclear  mem- 
brane which  is  thick  in  some  places,  and  thin  in  others. 

Sometimes,  but  not  always,  these  cells  possess  one,  or  even  two, 
true  nucleoli,  which  are  clearly  brought  out  by  fixation  with  chloride 
of  platinum  (Lowit).  They  may  also  be  seen  after  fixing  with 
sublimate,  and  staining  with  orange-haematoxylin. 

In  fact,  all  these  cells  have  sufficient  common  characteristics 
to  constitute,  in  appearance  at  least,  a  natural  family.  But  side  by 
side  with  these  resemblances  (small  size,  scantiness  of  protoplasm,  an 
almost  identical  arrangement  of  nuclear  chromatin,  etc.),  there  are 
differences  in  their  optical  properties,  in  the  staining  affinities  of  their 
protoplasm,  and  in  the  outline  of  their  cells  which  is  sometimes  regular, 
sometimes  irregular.  These  differences  are,  in  Hayem's  opinion, 
sufficiently  important  to  justify  a  distinction  into  two  classes  of 
cells :  viz.  the  clear  and  the  opaque  mononuclears  ;  the  latter 
correspond  to  the  lymphocytes  of  Ehrlich  ;  they  are  met  with  only 
in  the  lymph  ;  consequently  this  term,  which  indicates  their  origin, 
is  very  reasonable.  Dominici  makes  further  distinctions.  He 
describes,  by  the  side  of  the  ordinary  lymphocyte,  with  a  deeply 
stained  nucleus,  dotted  both  centrally  and  peripherally  with 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM     39 

granules  of  chromatin ;  with  slightly  basophile  or  clear  proto- 
plasm, identical  elements,  whose  only  special  characteristic  is  their 
power  of  emitting  protoplasmic  buds  which  can  detach  themselves. 
He  gives  to  this  physiological  stage  the  individuality  of  a  cellular 
type  which  he  defines  as  the  mother  cell  of  globulins.  Then,  under  the 
name  of  small  plasmacell,  he  describes  a  cell  with  a  deeply  stained 
nucleus,  and  extremely  basophile  protoplasm ;  under  the  name 
of  small  basophile  mononudear,  he  describes  an  element  with 
homogeneous  and  extremely  basophile  protoplasm,  but  whose  nucleus 
is  clear,  and  almost  destitute  of  chromatin. 

We  know  that  even  the  same  cell,  according  to  the  state  of  its 
nutrition,  its  repose,  and  the  mitosic  activity  of  its  nucleus,  shews 
considerable  variations  in  its  nuclear  chromatin  contents  and  in  its 
staining  properties ;  and  we  also  know  that  the  staining  reactions 
of  protoplasm  may  vary  in  the  same  element,  according  to  the 
phases  of  its  evolution ;  in  short,  the  power  of  detaching  small  frag- 
ments of  their  protoplasm  into  the  surrounding  media  is  a  very 
common  property  of  leucocytes.  We  may  therefore  suppose  that 
the  mother  cell  of  globulins,  the  little  plasmacell,  and  the  little  nuclear 
basophile  are  not  so  much  true  cellular  types,  with  special 
characteristics  and  individualities,  as  phases  of  the  same  element, 
which  vary  with  the  state  of  its  evolution,  nutrition  or  degeneration. 

The  microcytes  are  not  phagocytes  (Metchnikoff) ,  Their  amoebic 
properties,  which  are  altogether  denied  by  some  authors,  seem 
limited ;  but  they  exist  nevertheless  (Laguesse  Wolff,  Hirschfeld)  ; 
they  are  perhaps  inconstant  (Jolly). 

The  microcytes  are  met  with  normally  in  the  blood,  the  lymph, 
the  serous  fluid  from  the  peritoneum,  in  diffuse  or  circumscribed 
lymphoid  formations  near  the  epithelium,  especially  that  of  the 
digestive  tract,  in  lymphatic  glands,  in  the  spleen,  and  in  the  marrow 
of  bones. 

In  the  blood,  out  of  100  white  corpuscles,  there  are  from  22  to  25 
microcytes  (Ehrlich  and  Lazarus)  ;  Ouskoif  finds  20  to  25  ;  Mathias 
Duval  23  ;  and  Dumont  28- 5  out  of  every  100.  They  are  more 
numerous  in  young  children  (Voino-Oranski,  Ehrlich,  Engel),  less 
so  in  old  people,  from  75  and  upwards  (especially  rare  in  old 
people  of  90)  (Solovieff)  :  they  increase  during  lactation  (Ostro- 
gorsky),  during  digestion  (Rieder),  after  injection  of  pilocarpin 
(Waldstein,  etc.),  after  splenectomy  (Uskow,  Emilianoff,  Hartmann 
and  Vaquez).  In  the  latter  case,  Koroboff  has  seen  them  dimin'sh. 
They  increase  under  most  varied  morbid  causes,  viz.  lymphade- 


40  THE    LYMPHATICS 

noma,  malignant  lymphomas  (Ehrlich,  Karewski),  in  the  deteriora- 
tion of  blood  accompanying  tuberculosis  (Grawitz),  in  whooping 
cough  (Meunier).  They  diminish  after  extirpation  of  the  pancreas 
of  Aselli  (Rokitzky,  TchigaiefT)  ;  after  the  extirpation  of  several 
important  groups  of  glands,  Ehrlich  and  Reinbach  found  0'6 
in  every  100,  instead  of  25  for  every  100.  Koroboff  observed  their 
diminution  after  ligature  of  the  thoracic  duct ;  Omelianski,  after 
section  of  the  vasomotors. 

These  elements  are  most  numerous  in  the  lymph  :  Hayem 
found  in  the  lymph  taken  from  a  lymphatic  vessel  running  by  the  side 
of  the  carotid  artery,  only  "  opaque  inononuclears."  In  the 
thoracic  duct  of  the  dog,  out  of  133  elements  I  found  128  micro- 
cytes.  After  fixation  with  sublimate,  their  protoplasm  stained  well 
with  acid  colours.  They  predominate  also  in  the  cavernous  pas- 
sages of  the  lymphatic  gland. 

Though  they  are  usually  regarded  as  very  young  elements  by 
some  authors,  others  look  upon  them  as  old  and  degenerate  cells 
which  have  lost  their  protoplasm.  When  compared  with  other 
leucocytes,  it  is  interesting  to  observe  that  in  certain  pathological 
circumstances,  they  may,  without  any  increase  in  size,  become 
charged  with  neutrophile  granules  (Rieder).  They  then  become  the 
"small  pseudo-lymphocyte  neutrophiles  "  of  Ehrlich.  In  the  same  way, 
the  eosinophile  microcytes  are  sometimes  found  in  the  normal 
lymphatic  gland. 

We  must  again  insist  on  the  fact  that  there  are  no  precise  limits, 
in  regard  to  size,  between  these  elements  and  those  which  we  are 
about  to  study  under  the  name  of  macrocytes. 

Macrocytes 

Synonyms. — The  second  varietj'  of  Max  Schultze,  the  large  kinds  of  clear 
and  opaque  mononuclears  of  Hayem  ;  certain  macrophages  of  Metclmikoff  : 
certain  vacuolated  cells  of  Renaut  and  Lacroix  ;  megalocytes  of  Dumont ; 
polyeidocytes  of  Darier  ;  large  mononuclears  of  Lowit,  Ehrlich  ;  large 
lymphocytes  of  Denys,  Engel  ;  mature  and  old  leucocytes  of  Ouskoff  ;  large 
hyaline  cells  of  Gulland. 

The  Macrocytes  are  rounded  or  irregularly  oval,  and  in  the  blood 
range  from  15-17  p  ;  in  the  tissues  from  30-40  /u,.  They  are  the  largest 
leucocytes.  Their  protoplasm  is  abundant  and  often  presents 
vacuoles  ;  it  stains  more  feebly  than  the  nucleus  and  appears  slightly 
basophile  (Ehrlich).  The  protoplasm  of  macrocytes  which  has 
been  studied  in  the  tissues  (lymphoid  tissues)  is  either  extremely 
basophile  or  acidophile. 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM     41 

The  nucleus  is  large,  rounded,  or  nearly  quadrangular  ;  it  is  also 
found  to  be  reniform,  cordiform,  or  shaped  like  a  sac  ;  it  is  some- 
times double  or  even  triple  :  thus  these  cells  are  genuinely  poly- 
nuclear.  The  nucleus,  which  is  nearly  always  eccentrically  placed, 
is  somewhat  pale,  and  presents  one  or  two  true  central  nucleoli 
and  some  chromatin  granules  ;  the  chromatin  network  is  very 
delicate  and  disappears  readily  in  sections  which  are  badly  fixed. 

It  is  quite  clear  that  we  cannot  agree  with  Botkine  that  the  form 
and  dimensions  of  these  cells  entirely  depend  upon  artificial  altera- 
tions taking  place  in  a  mononuclear  medium. 

Ehrlich  does  not  include  in  the  large  mononuclear  class,  those 
elements  in  which  the  nucleus  is  reniform  ;  and  as  he  finds  in  their 
protoplasm  some  neutrophile  granules,  he  describes  them  under 
the  name  of  intermediate  forms,  i.e.  intermediate  between  non-granular 
leucocytes  with  a  rounded  nucleus,  and  granular  leucocytes  with  a 
polymorphous  nucleus.  It  has  been  remarked  that  these  inter- 
mediate cells  are  larger  than  the  polynuclears,  and  that  they  are 
rare  in  the  blood  ;  Ehrlich,  however,  does  not  admit  the  existence 
of  intermediary  forms  between  his  lymphocytes  and  his  large  mono- 
nuclears.  Here,  we  find  again  the  large  opaque  and  clear 
mononuclears  of  Hayem.  The  large  opaque  mononuclears  are 
always  smaller  than  the  clear  mononuclears.  If,  as  Hayem  thinks, 
there  are  no  intermediate  forms  between  the  clear  and  the  opaque, 
all  the  intermediate  forms  exist  between  the  large  and  the  small 
forms  of  each  of  these  two  series. 

The  macrocytes  are  amoebic,  and  extremely  phagocytic.  They 
digest  the  bacillus  of  Hansen,  red  corpuscles,  leucocytes,  and  par- 
ticles of  the  sulphate  of  arsenic  (Besredka). 

They  exist  in  the  blood,  the  lymph,  the  peritoneal  serous  fluid, 
the  connective  tissue,  lymphoid  formations,  lymphatic  glands,  the 
spleen  and  the  bony  marrow. 

In  the  blood,  out  of  100  leucocytes,  Ehrlich  counts  1  large  mono- 
nuclear,  2  to  4  transitional  forms  ;  Dumont  finds  1*5,  and  Hayem  13. 
per  cent.  This  difference  is  evidently  accounted  for  by  the  fact 
that  these  authors  have  not  adopted  the  same  arbitrary  line  of 
demarcation  between  the  micro-  and  the  macrocytes. 

In  the  lymph,  Hayem  found  only  large  opaque  mononuclears. 
In  that  of  the  thoracic  duct,  Dominici  found  macrophages 
and  basophilic  myelocytes.  In  the  thoracic  duct  of  the  dog,  I  have 
found  some  macrocytes  with  a  reniform  nucleus.  I  have  also 
seen  a  fair  number  of  vacuolated  and  non-vacuolated  macrocytes. 

D  * 


42 


THE    LYMPHATICS 


whose  protoplasm  almost  always  proved  to  be  acidophile  in  the 
lymph  spaces  of  the  normal  gland  of  the  rabbit.  These  elements 
increase  in  leuchaemia,  mycosis  fungoides  (Bensaude,  Leredde), 
malaria,  and  after  section  of  the  vasomotors  (Omelianski). 

Cells    with   Neutrophile    Granules 

Synonyms. — Third  variety-of  Max  Schultze  and  Hayem  ;  polynuclear, 
leucocyte,  or  rather  leucocyte,  with  a  polymorphous  nucleus  ;  one  of  the  micro- 
phases  of  Metclmikoff  ;  old  leucocyte  of  Ouskoff ;  cell  of  Kanthack  and 
Hardy  with  fine  oxyphile  granules  ;  neutrophile  myelocytes  of  Denys. 

These  cells  which  range  from  10  to  14  ^  in  normal  blood,  are 
easily  recognizable  by  the  well  marked  poly- 
morphism of  their  nuclei.  In  the  blood  of 
certain  leuchaemic  cases  and  in  the  marrow  of 
bones,  there  are  larger  cells  with  neutrophile 


FIG.  5. — Cells  with 
neutrophile  granules. 


granules,  and  a  round- 
ed nucleus  ;  it  is  for 
these  only  that  Erh- 
lich  has  reserved  the 
name  of  neutrophile 
myelocytes  (neutrophile  mononuclears). 
It  is  only  in  exceptional  cases,  that  cells  as 
small  as  microcytes  possess  neutrophile 
granules  (dwarf  corpuscles  of  Spilling, 
Rieder  and  Jolly  ;  small  neutrophile 
pseudo-lymphocytes  of  Ehrlich). 

The  polymorphous  nucleus  is  con- 
stricted into  two  parts,  and  twisted  in 
a  variety  of  ways  so  that  it  more  or  less 
resembles  the  letters  E  0  S  Y  Z.  It  is 
often  composed  of  2,  3  or  4  rounded 
masses,  or  twined  stalactiform  figures, 
but  more  usually  it  is  made  up  of  chro- 
matiii  filaments  so  fine  as  to  be  almost 
imperceptible.  This  nucleus  is,  in  turn, 
moniliform,  star-shaped,  and  bud-shaped. 
We  have  seen  that  many  causes  appear 
to  take  part  in  the  genesis  of  these  capri- 
cious forms.  Without  here  re-enumera- 
ting them  all,  we  will  simply  add  that  it 
very  frequently  happens,  as  has  been 
shewn  by  Denys  and  Jolly  that  the  annu- 


&•&:& 


m  & 


FIG.  6. — Annular  and  semi- 
annular  nuclei.  Those  in  the 
first  row  may  perhaps  be  ex- 
plained by  supposing  an  anomaly 
of  karyokinesis  (crown-like  ar- 
rangement of  the  chromosomes) ; 
an  incomplete  fragmentation 
may  account  for  those  in  the 
second  row.  The  others  arise 
from  the  approximation  of  the 
two  ends  of  the  tube-shaped 
nucleus. 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM     43 

lar  form,  whether  complete  or  incomplete,  arises  not  from  a  caryo- 
dieretic  anomaly,  but  from  the  simple  junction  of  the  free 
extremities  of  the  arciform  nuclear  mass. 

This  nucleus  possesses  a  network  of  strong  dense  chromatin  ; 
it  is  coloured  greenish  or  bluish  black  by  the  triacid. 

The  single  nucleus  (myelocyte  or  neutrophile  mononuclear  of 
Ehrlich)  is  large  and  is  perforated  by  holes  through  which  the 
cytoplasmic  granules  may  be  seen. 

The  protoplasm,  which  is  very  refracting,  stains  well  with  the 
acid  stains  (Ehrlich).  It  is  dotted  with  fine  granules,  which  are 
coloured  violet  by  the  triacid  (mixture  of  methyl  green,  orange,  and 
acid  fuchsin).  These  are  the  granules  which  Ehrlich  calls  neutro- 
philes.  We  have  already  alluded  to  the  discussions  which  the  staining 
affinities  of  these  granules  have  provoked.  They  are  soluble  in 
distilled  water,  potash,  and  in  acetic  acid  (3  in  100). 

The  cells  with  neutrophile  granules  are  very  amoebic,  and  very 
phagocytic.  Like  other  leucocytes  they  can  reproduce  themselves 
by  mitosis.  They  are  found  in  the  blood,  but  much  more  rarely 
in  the  lymph.  They  are  rare  in  the  glands  and  in  the 
spleen,  but  in  the  marrow  of  bones  they  are  again  much  more 
numerous. 

They  form  the  majority  of  the  white  corpuscles  of  the  blood  :  70  to 
72  in  100  (Einhorn) ;  70  to  80  in  100  (Ouskoff) ;  75  in  100  (Ehrlich  and 
Lazarus) ;  60  in  100  (Jolly) ;  66  in  100  (Leredde  and  Bezan£on) ;  67  in 
100  (Dumont).  They  appear  to  be  less  numerous  in  very  young 
infants  ;  viz.  28  to  4.0  in  100  (Goundobine) ;  40  in  100  (Jolly) ;  40  to 
50 in  100  (Besredka).  In  old  subjects  Jolly  finds  70  in  100. 

They  increase  during  digestion  (Ouskoff,  Leredde,  and  Loeper). 
They  increase  after  various  kinds  of  injections,  and  in  certain  intoxi- 
cations (abrin,  ricin)  (Gourevitch).  According  to  Yegorovski  they 
are  more  numerous  in  arterial  than  in  venous  blood. 

The  introduction  of  oxygen  into  an  arterial  segment  causes 
them  to  increase  (Yegorovski,  Markevitsch)  :  but  the  introduction 
of  the  same  gas  into  a  venous  segment  causes  them  to  diminish. 

Under  the  influence  of  chloroform  they  diminish  (Popoff)  ;  and 
the  same  thing  happens  with  pressure  (Vinogradoff). 

Though  Hayem  did  not  find  them  in  the  lymph  of  the  horse, 
Dominici  has  seen  them  in  that  of  the  thoracic  duct,  and  out  of 
133  leucocytes  counted  in  a  dog's  lymph  (thoracic  duct),  I  have 
observed  3  of  these  cells. 


44  THE    LYMPHATICS 

Cells   with   Acidophile    Granules 

Synonyms. — Fourth  variety  of  Max  Schultze  and  Hayem ;  leucocytes  of 
Semmer  ;  alexocytes  of  Hankin  and  Kanthack  ;  Eosiriophiles  ;  Myelocyte 
Eosinophiles  of  Denys. 

The  eosinophiles  are  as  a  general  rule  slightly  larger  than  the 
cells  with  neutrophile  granules,  and  have  a  rounded  or  a  polymor- 
phous nucleus.  Though  it  is  normal  to  find  only  the  leucocytes  of 
Semmer  with  a  polymorphous  nucleus  in  the  blood  of  the  healthy 
man,  the  variety  with  the  rounded  nucleus  exists  in  the  blood  of 
the  healthy  pig  and  horse  (Hirschfield,  Hayem).  It  is  for  this 

mononuclear     type      that 
Ehrlich  reserves  the  name 
of  eosinophile  myelocyte. 
w,.        ©'"!;  $  ^\  f)  The  nucleus  of  the  eosi- 

ej-         ©-  ^  nophiles    in    man  is,  as  a 

.;.>£,  rule,  a  little  less  stainable 

"*SP/-       »-•"  v-'.  than  that    of  the  neutro- 

Fio.  7. — Eosinophiles    with  a    single  nucleus,  and    philes.     Sometimes  formed 
a  polymorphous  or  multiple  nucleus.       Collection   of        ,  . ,  ..    .  ,,  , 

granules ;  histoiysis.  of  three,  it  is  usually  made 

up  of  two  nearly  equal 

rounded  or  oval  masses,  joined  or  not  by  a  fine  chromatin  filament. 
Jolly  lays  stress  on  this  arrangement,  which  has  been  figured,  but 
not  described  by  Hayem,  Renaut,  Hardy,  and  Wesbrook,  and 
Klein,  etc. 

This  nucleus  may  be  formed  by  an  arciform  mass  almost 
identical  with  that  of  the  neutrophile  potynuclears.  As  it  is  fre- 
quently perforated  the  cytoplasmic  granules  may  be  seen. 

In  the  protoplasm  are  found  more  or  less  numerous,  somewhat 
coarse,  spherical,  or  more  rarely  oval  granules,  which  are  very  re- 
fracting and  have  a  pale  yellow  tinge. 

These  granules  are  deeply  stained  by  the  acid  stains,  eosin, 
and  especially  by  orange  ;  the  periphery  stains  more  than  the 
centre  (Ehrlich).  With  thionin,  the  granules  are  stained  a  clear 
green  (Dominici).  They  are  not  stainable  with  osmic  acid.  They 
are  insoluble  in  alcohol,  ether,  chloroform,  essence  of  turpentine, 
sulphide  of  carbon. 

Unlike  haemoglobin,  and  in  spite  of  the  fact  that  it  contains  iron, 
this  granule,  according  to  Barker,  Lowit,  Sacharoff,  Tettenhamer, 
is  insoluble  in  water  (Schwarze,  Robin,  Malassez)  and  in  glycerine. 
It  is  insoluble  in  oil  of  cloves,  liquor  potassae  (3  in  100), 
acetic  acid  (which,  by  the  way,  is  prejudicial  to  its  ultimate  stain- 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM    45 

ing),    the    alkaline    bichromates,    sublimate,    formol,    and  chromic 
acid. 

By   reagents  de   Reichl   and  Mikosch,  Renaut  and  Weiss    have 
established  that  it  is  of  an  albuminoid  nature  (globulin) ;  and  Siawcillo 
also  finds  in  it  some  of  the  properties  of  the  albuminoids  :  he  finds 
it  is  stained  yellow  b}'  nitric  acid,  red  by  Millon's  reagent,  and  brown 
by  the  iodo-iodide    solution.      It  is    generally  agreed    that    it    is 
coloured  yellow  by  the  latter  reagent.     Is  this  difference  to  be  ex- 
plained  by    the    fact    that   Siawcillo    studied   the    eosinophiles    of 
the  ray  fish,  and  other  histologists  that  of  mammals  ?    On  the  other 
hand,  its  insolubility  in  gastric  juice  renders  it  akin  to  the  nucleins. 
If  it  has  been  clearly  shown  that  the  eosinophile  granules  represent 
neither  remains  of  cells,  as  Tettenhamer  and  Sacharoff  thought,  nor 
phagocyted  microbes,    as    Metchnikoff    and    Mesnil    asserted ;     if, 
contrary  to  the  opinion  of  Pouchet  and  Hayem,  it  can  be  shown  it  is 
not  a  question  of  haemoglobin,  it  is  more  difficult  to  understand 
what  ends  these  granules  serve,  which,  after  being  manufactured  and 
preserved   like   reserves  of   vitellin,  are   finally   collected   together 
in  the  tissues.  Hankin  and  Kanthack  regard  their  substratum  as  being 
composed  of  alexin,  a  mysterious  bactericidal  substance.     Altmann 
imagines  that  they  are  ozonophores  which  play  a  role  in  the  oxida- 
tions of  the  organism  ;    Cattaneo,  that  they  carry  a  ferment  which 
is  necessary  for  the  assimilation  of  certain  albuminoid  substances. 
Wagner  thinks  they  are  necessary  for  the  nutrition  and  formation 
of  different  eels. 

In  opposition  to  Renaut's  views,  several  authors  (Max  Schultze, 
BizzozerO;  Hayem,  Tschlenoff,  Miiller  and  Rieder,  Jolly)  have 
upheld  the  existence  of  amoebic  movements  in  the  leucocytes  of 
Semmer. 

Their  phagocytic  properties,  denied  by  Hankin  and  Kanthack, 
have  been  demonstrated  by  Dolega  and  Mesnil  :  they  are,  however, 
limited. 

The  eosinophiles  exist  in  the  blood,  lymph,  peritoneal  serous 
fluid,  the  connective  tissue  (in  the  neighbourhood  of  salivary,  gas- 
tric, intestinal,  mammary  and  bronchial  glands),  in  the  lymphatic 
glands,  the  spleen,  and  in  the  marrow  of  bones. 

Whereas  Michaelis  considers  there  is  a  relation  between  the 
abundance  of  eosinophile  secretions  and  the  suppression  of  an 
external  secretion  (viz.  mammary),  Bonne  has  more  recently 
maintained  that  the  bronchial  and  eosinophile  secretions  take 
place  simultaneously. 


46  THE    LYMPHATICS 

In  the  blood,  Ehrlich  reckons  2  to  4  eosinophiles  for  every  100 
white  cells  ;  Dumont,  2- 5  ;  Leredde  and  Loepei\  1  to  2  ;  Engel,  2  to  3  ; 
Canon,  2.  The  last  mentioned  author  found  in  infants  T06,  and 
2-31  per  cent,  and  in  old  subjects,  2- 09  ;  and  7  (in  a  man  of  88 
years  of  age)  per  cent. 

Eosinophiles  increase  under  the  influence  of  pilocarpin 
(Neusser),  and  iron  preparations,  after  splenectomy  and  in  the 
most  varied  morbid  conditions,  viz.  leuchaemia,  cutaneous  affections 
(pemphigus,  pellagra,  eczema,  psoriasis,  prurigo  scheroderma, 
syphilis),  vaccinia,  helminthiasis,  scurvy,  blennorrhagia,  tuber- 
culosis, scarlet  fever,  intermittent  fever,  asthma,  emphysema, 
psychosis,  neurosis.  They  diminish  or  disappear  at  the  crisis  of 
pneumonia  (Bettmann,  Engel),  of  typhoid,  of  rheumatism,  of  ery- 
sipelas (Bettmann). 

I  have  found  some  eosinophiles  in  the  lymph  of  the  thoracic  duct 
of  the  dog  (1  in  133),  as  have  also  Hayem  and  Dominici. 

Cells    with    Basophile    Granules,    Metachromatic, 
or    Cells    of    Ehrlich 

Synonyms. — Mastzellen  of  Ehrlich;  isoplastic  cells  of  Audry ;  basophile 
myelocyte  of  Denys. 

These  cells  vary  very  much  in  size  in  different  animals.  They 
range  between  8  and  12  p,  in  the  case  of  mammals;  and  in  batrachians 

the}r  vary  from  30  to  40  p. 

They  are  rounded,  polygonal,  elon- 
gated or  even  ramified  ;  in  the  latter 
case,  their  nucleus  is  sometimes 
central,  sometimes  polar ;  they  much 
resemble  clasmatocytes. 

The  nucleus,  which  is  often  masked 
by  granules,  is  sometimes  rounded,  or 


*•• 

**^  more    or    less    ovoid,    or    sometimes 

FIG.  8.—  Ceils  of  Ehrlich.     in  some  polymorphous   (bi-   or  trilobed)       In 

of  them,  the    granules   are    dissolved.  ' 

it  should  be  noticed    how    owing  to  the  cells  ol  JMirlicli,  taken  from  Ivm- 
' 


Phatic     8lands>    J    have    constatly 
found  a  rounded  nucleus    somewhat 

like  that  of  microcytes.     It  differs  from  it  in  its  lesser    staining 

capacities   (Pappenheim). 

This  nucleus  is  coloured  pale  blue  by  the  polychromatic  blue 

of  Unna  ;  it  has  a  fine  membranous  capsule,  and  some  fine  chromatin 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM        47 

granules.  In  the  protoplasm  are  found  granules  whose  form, 
dimensions,  and  distribution  are  irregular. 

Rounded  or  cocciform,  these  granules  are  sometimes  finer 
than  the  eosinophiles,  sometimes  as  coarse,  sometimes  even  they 
are  of  larger  size  (Engel).  In  some  cells,  they  are  closely  packed ; 
in  others,  they  are  further  apart. 

These  granules  are  soluble  in  distilled  water,  in  acetic  acid  (3  in 
100),  and  in  Adam's  fluid  ;  they  are  insoluble  in  alcohol,  and  in 
alcoholic  ether.  They  stain  with  Gram  and  Ziehl ;  also  with 
dahlia,  but,  treated  with  carbonate  of  potash  they  become  dis- 
coloured ;  this  is  not  the  case  with  microbes. 

By  analogy,  it  may  be  asked  if  these  granules  do  not  owe 
their  resistance  to  decolorization  by  strong  acids,  to  the  presence  of 
a  fatty  covering.  In  any  case,  they  do  not  stain  black  with  osmic 
acid. 


FIG.  9. — Clasmatocytes  of  the  triton  (after  Ranvier). 

With  thionin,  and  Unna's  blue,  they  yield  a  red,  that  is  to  say 
metachromatic  tint,  analogous  to  that  of  mucus  but,  more  intense. 
They  stain  almost  pure  brown  with  extra-kresyl  violet.  Nordmann 
and  Raudnitz  think  these  granules  are  neither  composed  of 
amyloid  material  nor  of  mucus. 

Besides,  if  the  metachromatic  red  is  obtained  not  only  with 
the  granules  of  Ehrlich's  leucocytes,  but  also  with  mucus,  and  with 
the  fundamental  substance  of  hyaline  cartilage  and  Wharton's  Jelly, 
it  also  manifests  itself  with  the  most  varied  chemical  substances, 
(nitric  and  sulphuric  acids,  potash,  chloroform,  acetone,  anilin,  oil 
of  cedar). 

It  is  not  unusual  to  see  Ehrlich's  cells  shed  their  granules  around 
them  ;  sometimes  the  granules  are  set  at  liberty  after  having  been 
previously  dissolved  in  the  protoplasmic  body. 


48  THE    LYMPHATICS 

By  their  form,  their  mode  of  secretion,  the  cells  of  Ehrlich  are 
very  similar  to  those  of  Ranvier  (clasmatocytes).  In  the  batra- 
chians,  the  analogy  is  complete ;  in  mammals,  there  is  one 
difference,  viz.  metachromatism  does  not  exist  in  the  granules 
of  the  clasmatocytes  (Jolly).  Does  this  difference  justify  us  in 
making  a  Avide  distinction  between  two  elements  which  are  similar 
in  so  many  respects  ? 

In  the  first  place,  it  has  not  yet  been  proved  that  met- 
achromatism is  a  chemical  phenomenon ;  and  even  if  we  admit 
there  is  a  difference  of  chemical  constitution  between  the  meta- 
chromatic  basophile  granules  and  the  non-metachromatic,  this 
difference  does  not  seem  sufficient  to  justify  us  in  making  a  com- 
plete distinction  between  two  orders  of  elements  whose  comparative 
anatomy  shows  them  to  have  such  intimate  affinities.  Besides, 
are  not  the  red  blood  corpuscles  of  different  animals  morphologically 
and  functionally  identical,  in  spite  of  a  very  real  difference  in  their 
chemical  constitution  ? 

The  cells  of  Ehrlich  exist  in  the  blood,  in  serous  liquids.1  in  the 
perivascular  connective  tissues  of  the  great  omentum,  in  the  dermal 
papillae,  in  the  submucous  coat  of  the  intestines,  often  in  the  con- 
nective tissue  spaces  of  the  liver,  also  in  the  lymphatic  glands,  the 
spleen,  and  the  marrow  of  bones. 

They  are  very  rare  in  human  blood  ;  Ehrlich  and  Lazarus  finding 
only  0-5  in  100  as  the  maximum,  Canon  0'28  in  100.  According  to 
Canon,  they  are  apparently  more  abundant  in  the  blood  of  infants 
(0'88  to  1-86  in  100).  Zollikofer  has  found  them  in  larger  numbers 
in  the  blood  of  subjects  afflicted  with  sciatica,  hysteria,  and  acute 
rheumatism.  After  the  injection  of  pyrodin,  Schmauch  has  seen 
them  increase,  as  has  Levaditi,  after  the  injection  of  the  toxins 
of  staphy  ococc'. 

In  the  blood  of  the  rabbit,  Bauer  finds  2  to  5  in  100  ;  Levaditi,  4*3  in 
100.  Now,  these  cells  are  without  doubt  very  rare  in  the  connective 
tissue  of  this  animal.  It  is  interesting  to  remark  that  Ehrlich's  cell 
is  as  scarce  in  the  blood,  as  it  is  abundant  in  the  connective  tissue. 
This  is  a  law  common  to  almost  all  the  leucocytes  of  the  higher 
normal  vertebrates  :  thus  the  macrocytes  and  eosinophiles,  which 
are  rare  in  the  blood,  abound  in  the  connective  tissue  ;  and  the 
microcytes  and  neutrophiles,  which  are  found  in  quantities  in  the 
blood,  are  rare  or  are  absent  in  the  connective  tissues. 

1  Milchner  has  found  several  in  ascites  in  a  leuchaemic  case,  Xeisser  in 
the  exudate  of  a  blennorhagia. 


GENERAL    ANATOMY  OF  THE  LYMPHATIC  SYSTEM    49 

Ballowitz  has  stated  that  the  cells  of  Ehrlich  are  scarce  in  the 
connective  tissues  of  the  rabbit,  the  hare,  the  guinea-pig,  and  birds  ; 
but  that  he  has  observed  many  in  the  dog,  the  calf,  the  goat, 
the  rat,  and  the  bat.  In  the  latter  case,  he  has  found  them  as 
numerous  after,  as  before  hibernation.  On  the  contrary,  in  the  case 
of  a  well  nourished  frog  which  has  been  kept  warm,  Korybutt, 
Daskiewicz,  and  subsequently  Stassano  and  Hass,  have  seen  both 
the  cells  of  Ehrlich  and  the  clasmatocytes  increase.  According  to 
Unger,  the  suppression  of  the  lacteal  secretion  determines  the  in- 
crease of  these  elements  in  the  breast.  On  the  other  hand,  West- 
phal  has  found  numbers  of  them  in  the  cachectic.  As  Rosenheim 
has  remarked,  their  multiplication  is  quite  independent  of 
hypernutrition,  and  Friedlander,  Gleumann,  and  Ballowitz  have 
quite  rightly  found  but  little  to  justify  the  expression  of  Mastzelle 
which  has  been  given  them  by  Ehrlich. 

They  are  found  in  various  pathological  products,  e.g.  liponiata, 
cutaneous  tubercles  (Westphal,  Bergonzini),  urticaria  pigmentosa 
(Unna),  the  peri-cancerous  zone  (Ballowitz),  miliary  epidermic 
vesicles,  sarcomata  (Ackermann),  nodules  of  glanders,  brown  in- 
duration of  the  lung  (Israel),  acute  neuritis  (Rosenheim),  foci  of 
cerebral  haemorrhage  and  multiple  sclerosis  (Neumann),  in  the 
skin  of  general  paralytics  (Franca  and  Athias),  and  in  sleeping  sick- 
ness (Athias).  Even  supposing  that  in  some  of  these  morbid  cases 
there  is  really  a  local  hypernutrition,  it  is  quite  evident  that  in 
certain  others  at  least,  there  is  on  the  contrary,  a  true  diminu- 
tion of  the  local  nutrition  (lipoma,  sleeping  sickness,  general 
paralysis). 

In  speaking  of  each  leucocyte,  we  have  indicated  the  proportion 
in  which  it  is  found  in  the  blood  :  this  proportion  is  usually 
sufficiently  variable  to  make  it  difficult  to  determine  the  normal 
and  exact  limits,  of  what  has  been  called  "  leucocytary  equilibrium" 
Besides,  haematologists  are  hardly  agreed  in  fixing  the  mean 
quantity  of  white  corpuscles  contained  in  a  cubic  millimetre 
of  blood.  Hayem  fixes  it  at  6,000  ;  Ranvier  at  8,000  ;  Dumont 
at  7,650.  All  numbers,  therefore,  above  7,500  cannot,  as  has 
been  stated  by  Leredde  and  Loeper,  be  regarded  as  pathological. 

BIBLIOGRAPHY. — Leuwenhcek.  Opera  omnia  s.  arcana  natural  detecta.  Lugcl. 
Batav.,  1722. — Delia  Tore.  Nuove  osservazzione  microscopiche.  Napoli, 
1776. — Wharton  Jones.  The  blood  corpuscle  considered  in  its  different 
phases  of  development.  Philosophical  Transactions,  1846. — Davaine. 
Memoires  de  la  Societe  de  Biologic,  1850. — Moleschott.  Ueber  die  Etwickne- 


70  THE    LYMPHATICS 

lung    der    Blutkorperchen.     Archiv    f.    Anal.    u.    Phys.,     1853. — Virchow. 
Verh.   der  phys.   med.    Ges.   zu    Wurzburg,   II,   p.    325  ; — Virchow' s   Archiv, 
1853,  V,  p.   43. — Lieberkiihn.     U.   Psorospermien.     Mullet* s  Archiv,    1854. 
—Robin.      Sur  quelques  points   de  1'anatomie  et  de    la    physiologic    des 
leucocytes.     Journ.   de  Phys.,    1859,   II,   p.   41. — Heckel.     Die  Radioldren, 
1S62. — Recklinghausen.     Ueber   Eiter   u.    Bindegewebe-Korperchen.       Vir- 
chow's Archiv,  XXVIII. — Kuhne,  Unters.   ueber  das  Protoplasma  u.   die 
Contractilitat,    1864. — Max  Schultze.      Ein  heizbarer  Objecttisch  u.   seine 
Verwendung  bei  Untersuch.    des  Blutes.    Arch.   f.  mikrosk.  Anat.,  1865,  I. 
— Cohnheim.    U.     Entziindurig  u.  Eiterung.      Virchow's  Arch.,   1867,  XX. 
— Bizzozero.     Sul  processo  di  cicatrizzione  dei  tendiiii  tagliati.     Ann.  univ. 
di  medicina,  1868,  CCIII. — Preyer.     Centralblatt   /.  die  medic.     Wissensch., 
1869,  p.  305. — Klein.  U.  die  Theilung  farbloser  Blutkorperchen.    Centralbl. 
f.  d.  med.  Wiss.,  1870,  n°  8,  p.  17. — Rouget.    Migrations  et  metamorphoses 
des  globules  blancs.     Arch,  de  Phys.,  1874. — Semmer.   Inaug.  Diss.,  Dorpat, 
1874. — Ranvier.    Recherches  sur  les  elements  du  sang.     Archives  de  Phys., 
1875. — S.  Mayer.    Arch.  f.  mikr.  Anat.,  XIII. — Waldeyer,  Ueber  die  Binde- 
gewebszellen.    Arch.   f.   mikr.   Anat.,    1875,   XI.— v.   Roietzky.     Contrib.   a 
1' etude  de  la  fonction  hematop.  de  la  moelle  osseuse.    Arch.  Sciences  biol., 
Petersbourg,  1877. — Vulpian.    C.  R.  Acad.  Sciences,  4  juiii  1877. — Ehrlich. 
Beitrage  zur  Kentniss  der  granulierteii  Bindegewebszellen  u.  der  eosinoph. 
Leucocyt.  Archiv  f.  Anat.  u.  Phys.,  1879  ; — Ueber  die  specifischen  Granula. 
tionen  des  Blutes.      Verhandl.  d.  physiol.  Gesellschaft  zu  Berlin,  1878-1879- 
n"  20. — Peremeschko.    U.    die  Theilung  der  Zellen.     Centralbl.  f.   d.  med., 
Wissenschaft,  1878. — Korybutt  Daskiewicz.   Arch.  f.  mikr.  Anat.,  1878,  XV  ; 
— Arch.  f.  mikr.  Anat.,  1880,  XVII. — Pouchet.    Note  sur  les  leucocytes  et 
la  regeneration  des  hematies.    C.  R.  Soc.  Biol.,  5  Janvier  1878  ; — Evolution 
et  structure  des  noyaux  des  elements  du  sang  chez  le  triton.     Journ.  de 
VAnat.    et   de    la   Phys.,    1879. — Hayem.     Recherches   sur   1'evolution     des 
hematies.     Arch.  phys.  norm,  et  path.,  2'  serie,  VI,   1879. — Flemming.    U. 
das  Verhalten  des  Kerns  bei  der  Zelltheilung  u.  liber  die  Bedeutung  mehr- 
kernigen  Zellen.      Virchow's  Arch.,  1879,  LXXVII  ; — Beitrage  zur  Kentniss 
der  Zelle  u.   ihr.   Lebenserscheinungen ,   I  Theil.    Arch.   f.   mikrosk.   Anat., 
1879,    XVI  ; — Archiv.  f.    mikr.    Anat.,    1882,    XX  ; — Zellsubstanz,    Kern  u. 
Zelltheilung,    1882. — Westphal.     Ueber    Mastzellen.     Inaug.    Diss.,  Berlin, 
1880. — Spilling.     U.     Blutuntersuchungen    bei    Leukamie.     Inaug.    Diss., 
1880. — Ehrlich.     U.    die   Bedeutung    der    neutrophilen    Kornung.     Charite 
Annalen,  XIII  ; — Methodologische  Beitrage  zur  Phys.  u.  Pathol.  der  ver- 
schiedenen   Formen   der   Leukocyten.     Zeitschrift   f.    klin.    Med.,    1880,    I. 
— Schwarze,    Ueber    eosinoph.     Zellen.     Inaug.    Diss.,    Berlin,    1880. — Ch. 
Robin.    Sur  les  corpuscules  nucleiformes  des  leucocytes.  Journ.  de  Phys., 
1881. — Certes.   C.  R.  Acad.  Sciences,  1881,  XCII,  n"  8. — Renaut.   Recherches 
sur  les  elements  du  sang.    Arch,  de  Phys.,  1881. — Schoefer.     British   Med. 
Jour.,    1882,  n°   1134,   p.   573. — Israel,    Berlin,   kl.    Wochenschr.,    1883. — S. 
Arnold.      Virchow's  Archiv,  1882  ; — Beobacht.  u.  Kerne  u.  Kerntheilungen 
in  den  Zellen  der  Knochenmarkes.     Virchow's  Archiv,   1883,  LXXXVIII  ; 
—  Virchow's    Arch.,    1884,    XCV. — Raudnitz.     Arch.     f.    mikrosk.     Anat., 
1883,    XXII. — Ackermann.       Volkmann's   Sammlung,   Klinischer    Vortrdge, 
1883. — Einhorn.    Inaug.  Diss.,  Berlin,   1884. — Bizzozero.     Virchow's  Arch., 
1884. — Lavdovsky.      Mikroskopische    Untersuch.    einiger    Lebensvorgange 
des  Blutes.      Virchow's  Arch.,    1884,   XCVI. — Bizzozero.     U.    die  Bildung 
der   rothen    Blutkorperchen.      Virchow's    Arch.,    1884,    XCV. — Nordmann. 
Beitrage  zur  Kentniss  u.  namentlich  zur  Farbung  der  Mastzellen.     Diss., 


GENERAL    ANATOMY  OF  THE  LYMPHATIC  SYSTEM  51 

Berlin,  1882  ; — Internal.  Monatsch.  f.  Anat.  u.  Hist.  1885,  II. — Lowit.  U. 
die  Bildung  der  rothen  u.  weisser  Blutkorp.  Sitz.  derK.  Akad.der  Wissensch. 
Wien,  1883,  III  ; — U.  Neubildung  u.  Zerfall  der  weissen  Blutkorperchen. 
Sitz.  der  K.  Akad.  der  Wissench.  Wien,  1885,  XCII,  p.  121. — Neumann. 
Ueber  Plasmazellen.  Von  d.  med.  Fakultat  d.  univ.  Rostock  gekronte 
Preissclirift.  Rostock,  1885. — Rosenheim.  Ueber  das  Vorkommen  u.  die 
Bedeutung  der  Mastzellen  im  Nervensystem  der  Menschen.  Arch.  f.  Psych. 

u.    Nervenkrank.,    1886,    XVII. — Prus.     Medycyna,    1886,    n01    30   et   40. 

Pfitzner.  U.  Theilungsvorgange  an  den  Leukocyten,  ihre  progressiven  u. 
regressiven  Metamorphosen.  Arch.  f.  mikr.  Anat.,  1887,  XXX. — Denys. 
La  cytodierese  des  cellules  geantes  et  des  petites  cellules  incolores  de  la 
moelle  des  os.  La  Cellule,  1887,  II,  p.  245; — La  structure  de  la  moelle  des 
03  et  la  genese  du  sang  des  oiseaux.  Ibid.,  1887,  IV. — Schultze  Die  vitale 
Methylenblaureaction  der  Zellgranula.  Anat.  Anzeig.,  1887. — Arnold. 
Ueber  Theilungsvorgange  an  der  Wanderzellen.  Arch.  f.  mikrosk.  Anat., 
1887,  p.  205  ; — Weitere  Beobacht.  u.  Theilungsvorgange  an  der  Knochen 
Markszellen  u.  weissen  Blutkorperchen.  Virchow's  Arch.,  1887,  XCVII  ; 
— Alter  u.  Neues  iiber  Wanderzellen  insbesondere  deren  Herkunft  u. 
Umwandlungen.  Virchow's  Arch.,  CXXXII. — Kultschitsky.  Karyokinesis 
in  farblosen  Blutkorp.  Centralbl.  /.  die  med.  Wissenschajt,  1887. — Leber. 
Fortschritte  der  Medicin,  1888,  VI. — Lubarsch.  Fortschr.  d.  Medicin.,  1888, 
VI,  n°  4  ;— Centralbl.  f.  Bakt.,  VI,  n08  18,  20.— Spronck.  Over  Regenerate 
in  Hyperplasie  van  Leukocyten  in  het  circuleirend  bleed.  Nederlandsch 
Tydschrift  voor  Gesselskunde,  29  mars  1889. — Prins.  Karj'okinese  in  het 
blood  by  intgebreide  etherings  processen.  Diss.  Utrecht. — Korschelt. 
Zool.  Jahr.  Abtheil.  f.  Anat.  der  Thiere,  1889. — Hermann.  Arch.  /.  mikr- 
Anat.,  1889,  XXXIV,  p.  100.— Peckelharing.  Sem.  med.,  1889,  n°  22,  p.  184 
— Marchand.  Ziegler's  Beitrdge,  1889,  IV. — Hayem.  Du  sang  et  de  ses  alter, 
ations  anatomiques,  Paris,  1889,  p.  110. — Lowit.  U.  die  Beziehung  d.  weissen 
Blutkorp.  zur  Blutgerinnung.  Ziegler's  Beitrage,  1889,  V. — Xaumann.  U. 
das  Vorkommen  der  sogen.  Mastzellen  bei  pathol.  Veranderurigen  des 
Gehirns.  Vinhow's  Archiv,  1890,  CXXII,  2.— H.  F.  Muller.  Zur  Leukamie- 
frage.  Deut.  Arch.  f.  klin.  Med.,  1890. — Obrastzow.  Deut.  med.  Woch., 
1890. — Massart  et  Bordet.  Recherches  sur  1'irritabilite  des  leucocytes 
et  sur  P intervention  de  cette  irritabilite  dans  la  nutrition  des  cellules  et 
dans  rinflammation.  J.  de  la  Soc.  R.  des  Sciences  med.  et  nat.  de  Bruxelles, 
1890. — Gabritchevsky.  Sur  les  proprietes  chimiotaxiques  des  leucocytes. 
Annales  de  VInstitut  Pasteur,  1890. — Buchner.  Die  chemische  Reizbarkeit 
der  Leukocyten  u.  deren  Beziehung  zur  Entziindung  u.  Eiterung.  Berlin, 
klin.  Wochenschrift,  1890. — Auerbach.  U.  die  Blutkorperchen  der  Batrachier. 
Anat.  Anzeiger,  1890. — Uskoff.  Le  sang  comme  tissu.  Petersbourg,  1890. 
— Ranvier.  Des  clasmatocytes.  C.  R.  Acad.  Sciences,  27  Janvier  1890  ; — 
Sur  les  elements  anatomiques  de  la  serosite  peritoneale.  C.  R.  Acad. 
Sciences,  14  avril  1890. — Rosbach.  Deut.  med.  Woch.,  1890,  p.  389.— 
Brigidi.  Lo  Sperimentale,  settembre  1891. — Pacinotti.  Intorno  alle  cellule 
granulose  di  Ehrlich  o  mastzellen.  Giorn.  della  R.  Accad.  di  medicina  di 
Torino,  1891,  n°  6. — Flemming.  LT.  Theilung  u.  Kernformen  bei  Leukocyten 
u.  iiber  deren  Attractionspharen.  Arch.  f.  mikrosk.  Anat.,  1891,  XXXVII  ; 
— Attractionspharen  u.  Centralkorper  in  Gewebszellen  u.  Wanderzellen. 
Anat.  Anzeiger,  1891,  VI. — V.  der  Stricht.  Div.  mitosique  des  erythroblastes 
et  des  leucoblastes  a  1'interieur  du  foie  embryonnaire  des  mammiferes. 
Anat.  Anzeiger,  1891. — Dekhuysen.  U.  Mitosen  in  frei  im  Bindegewebe 
gelegenen  Leukocyten.  Anat.  Anzeiger,  1891,  VI. — Gulland.  The  nature 


52  THE    LYMPHATICS 

and  varieties  of  leucocytes.  Rep.  Lab.  Roy.  Coll.  Phijs.  Edinburgh,  1891, 
HI. — Weiss.  Das  Vorkommen  u.  die  Bedeutung  der  eosinoph.  Zellen  u. 
ihre  Beziehung  zur  Bioblasteatheorie  Altmanri's.  Wien.  med.  Presse,  1891 
n**  41-44. — Muller  u.  Rieder.  U.  das  Vorkommen  u.  klinische  Bedeutung 
der  eosinoph.  Zellen  (Ehrlich)  im  circulirenclen  Blute  der  Menschen. 
Deut.  Arch.  f.  klin.  Med.,  1891,  XL VIII,  p.  96. — Ranvier.  Transformation 
in  vitro  des  cellules  lymphatiques  en  clasmatocytes.  C.  R.  Acad.  Sciences. 
6  avril  1891. — Griesbach.  Beitrage  zur  Histologie  der  Blutes.  Arch.  /. 
mikr.  Anat.,  1891,  XXXVII,  p.  22  ; — Struktur  u.  Plasmoschise  der  Amce- 
bocyten.  Verhandl.  d.  Anat.  Ges.  Munchen,  1891. — Bergonzini.  U.  das 
Vorkommen  von  granulierten  basophileii  u.  acidophilen  Zellen  im  Binde- 
gewebe  u.  iiber  die  Art  sich  sichtbar  zu  machen.  Anat.  Anzeiger,  1891. 

H.  F.  Muller.    U.  Mitose  an  eosinoph.    Zellen.  Arch.  f.  experim.  Path.. 

1891. — Muller.  Deut.  Arch.  f.  klin.  Med.,  1891,  XLVIII. — Muir.  Journ.  of 
Anat.  and  Phys.,  1891,  XXV. — Ballowitz.  U.  das  Vorkommen  der  Ehr- 
lich'schen  granulierten  Zellen,  "  Mastzellen "  bei  winterschlafenden 
Saugethieren.  Anat.  Anzeig.,  1891. — V.  Bambeke  et  van  der  Stricht. 
Caryomitose  et  div.  indirecte  des  cellules  a  noyau  bourgeonnant.  Ann. 
Soc.  de  Med.  de  Gand,  1891. — Lowit.  U.  amitotische  Kerntheilung.  BioL 
Centralblatt,  1891,  XI  : — Anat.  Anzeiger,  1891  ; — U.  Neubildung  u.  Bes- 
chaffenheit  der  weissen  Blutkorp.  Beitrage  z.  path.  Anat.,  von  Ziegler,  1891, 
X. — Ostrogorski.  Contrib.  a  1* etude  des  modific.  morphol.  du  sang  pendant 
la  grossesse,  1' accouchement  et  la  periode  postpuerperale.  Th.  Peters- 
bourg,  1891. — Hansemann.  Ein  Beitrag  zur  Enstehung  u.  Vermehrung  der 
Leukocyten.  Verh.  der  Anat.  Gesellsch.  Munchen,  mai  1891  ; — Anat.  Anzeiger. 
— Gceppert.  Kerntheilung  durch  indirecte  Fragmentierung  in  der  lymphat. 
Rnnclschicht  der  Salamanderleber.  Arch.  /.  mikr.  Anat.,  1891,  XXXVII. 
— Weiss.  Eine  neue  mikrochemische  Reaction  der  eosinoph.  Zellen. 
CentralbL  f.  die  medicin.  Wissensch.,  1891. — Cuenot.  Etude  sur  le  sang  et 
les  glandes  lymphatiques  dans  la  serie  animale.  Arch.  Zoologie  exp.  et 
gen.,  1891,  2""' serie,  7-9. — Scarpaletti.  U.  die  eosinoph.  Zellen  des  Kanin- 
chen-Knochenmarkes.  Arch.  f.  mikrosk.  Anat.,  1891. — Unna  .  Monatschr. 
f.  prakt.  Dermat.,  1891,  XII. — Schaffer.  Ueber  das  Vorkommen  eosinoph. 
Zellen  in  der  menschlichen  Thymus.  CentralbL  f.  d.  n^cd.  Wissensch.,  1S91. 
— Hock  u.  Schlesinger.  Blutuntersuchungen  bei  Kindern.  CentralbL  f. 
klin.  Med.,  1891,  n0  46.—  Netchaeff.  Virchow's  Arch.,  1891,  CXXV.— 
Wertheim.  Zeitschr.  /.  Heilkunde,  1891,  XII.— Noll.  Wiener  med.  Presse, 
1892. — Unna.  Zeits  f.  iviss.  Mikrt.,  1892,  VIII  4;  IX. — Bastianelli.  Boll,  della 
R.accademiamed.di  Roma,  1892,  XVIII. — Voi'no  Oranski.  Morphol.  du  sang 
chez  les  nouveau-nes.  Th.  Petersbourg,  1892. — Goundobine.  De  la  mor- 
phologie  norm,  et  path,  du  sang  chez  les  enfants.  Th.  Petersb.,  1892. 
— M.  Heideiihain.  U.  die  Centralkorpergruppen  in  den  Lymphocyten  der 
Saugethiere  wahreiid  der  Zelleiiruhe  u.  Zelltheilung.  Verhandl.  d.  anat. 
Gesellsch.  Gottingen,  1892  ; — Festschr.  Kolliker,  Leipzig,  1892. — Canon.  U. 
eosinoph.  Zellen  u.  Mastzellen  im  Blut  Gesunder  u.  Krankeit.  Deut.  med. 
Woch.,  1892,  n°  10. — Muller.  U.  Mitose  an  eosinoph.  Zellen.  Beitrag  zur 
Kentniss  der  Theilung  der  Leukocyten.  Arch.  /.  exp.  Path.  u.  Pharmak., 
1892,  XXIX. — Rieder.  Beitrage  zur  Kentniss  der  Leukocytose.  Leipzig, 
1892. — Lowit.  Studien  zur  Phys.  u.  Path,  des  Blutes  u.  der  Lymphe.  lena, 
1892. — Lilienfeld.  Hamatol.  Untersuchungen.  Arch.  f.  Anat.  u.  Phys., 
1892. — Everard  et  Demoor.  Les  modifications  des  globules  blancs  dans  les 
maladies  infectieuses.  Soc.  Sc.  med.  et  nat.  Bruxelles,  1892. — Everard 
Massart  et  Demoor.  Annales  de  Vlnstitut  Pasteur,  VII,  p.  165. — Grawitz, 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM     53 

Ueber  die  schlummernden  Zellen.  der  Bindegewebes  u.  ihre  Verhalten  bei 
progressiven  Emahrungsstorungen.  Virchow's  Archiv.,  1892,  CXXVII. — 
Mesnil.  Annales  de  VInstitut  Pasteur,  IX,  p  301. — Zappert.  U.  das  Vorkom- 
men  der  eosinoph.  Zellen  im  mensch.  Blute.  Zeitschrift  f.  klin.  Med., 

1892,  XXIII,  p.   227.— Kourloff.     Wratch,   1892.— Ranvier.    Les  clasmato- 
cytes,  les  cellules  fixes  du  tissu  conjonctif  et  ies  globules  du  pus.   G.  R. 
Acad.  Sciences,   1893,  CXVI,  n°  7,  p.  295.— Hericourt  et  Richet.     Modifi- 
cations dans  le  nombre  des  leucocytes  du  sang  apres  injection  de  diverses 
substances.     C.  R.  Soc.  Biol,  1895,  n°  35,  p.   965.— Medwedeff.    Comment 
se  comportent  les  leucocytes  vis-a-vis  de  certaines  substances  introduites 
dans  le  sang.     These  Petersbourg,    1893. — Golzmann.     Contrib.  a  I'etude  de 
la   leucocytose.     Th.    Petersbourg,    1893; — Gaz.    hebd.    med.    Russie  merid., 
1894,  ii"  46.— Schulz.    Deut.   Arch.  f.   klin.  Med.,    1873,   LI.— E.   Botkine.- 
Influence  de  1'albumine  et  des  peptones  sur  quelques  fonctions  de  1'organisme. 
These    Petersbourg,     1893. — Autonenko.     Modific.    morphol.    du   sang   sous 
ririfluence  de  la  saignee.    These  Petersbourg,  1893. — Wladimiroff.  Modific.  mor- 
phol. du  sang  sous  1'influence  des  modif.  de  la  pression.    Th.  Petersb.,    1893. — 
Cueriot.  Evolution  des  amibocytes  chez  les  crustaces  decapodes.  Bibliogr.  anat., 

1893,  p.  157. — V.  der  Stricht.   Nature  et  div.  mitosique  des  globules  blancs  des 
mammiferes.    Verhandl.  der  anat.  GesellschafftinGottingen,1893. — Klein.  Die 
diagnostiche   Verwerthung    der    Leukocytose.     Sammlung.    klin.    Vortrdge, 

1893,  11°  87. — Tettenhamer.    U".  die  Enstehuiig  der  acidophilen  Leukocyten. 
Granula    aus    degenerirender    Kernsubstanz.     Anat.    Anzeig.,    1893,    VIII, 
p.  223. — Tschistowitsch.   Contrib.  a  Fetude  de  la  leucolyse.   Gaz.  de  Botkinet 

1894,  n"  9. — E.  Botkine.    Solubilite  des  leucocytes  dans  la  peptone.    Gaz. 
de  Botkine,   1894,   n°  22. — Omelianski.    De  1'influence  des  troubles  circu- 
latoires  locaux  sur  la  morphologic  du  sang.     These    Petersbourg,    1894. — 
Yegorovski.    Modific.  morphologiques  des  globules  blancs  dans  les  vaisseaux 
sanguins.     These  Petersbourg,    1894. — Vinogradoff.      Contrib.   a  l'6tude  de 
la  pression  arterielle  sur  la  morphologie  du  sang.    These  Petersbourg,  1894. 
— Przevosky.    Soc.  med.  de   Varsovie,  nov.   1894. — Rokitzki.    Modifications 
morphologiques  du  sang  chez  les  chieiis  apres  1' ablation  du  pancreas  d'Aselli. 
These  Petersbourg,   1894. — Solovieff.     Examen  du  sang  chez  les  vieillards. 
Th.   Petersbourg,    1894. — Sherrington.     Proceedings  of  the  Royal  Society  of 
London,   1894,   LX,  p.    187. — Onimus.    ISTaissance  des  leucocytes  dans  les 
liquides  amorphes.    C.  R.  Soc.  Biologie,  1894,  11"  25,  p.  651. — Unna.    Zeit  f. 
wiss.  Mikr.,   1894,  XI,  4,  p.   511  ; — Monatsschrift  f.  prakl.  Dermat.,   1894, 
XVIII. — Zenoni.    U.  die  Enstehung  der  verschied.    Leukocytenformen  des 
Blutes.    Zeigler's  Beitrdge,  1894,  XVI,  p.  537. — M.  Heidenhain.    U.  Bau  u. 
Funktion   der    Riesenzellen    (Megakaryocyten)    im    Knochenmark.      Wilrz- 
burger  Verhandl.,  1894. — Kanthack  a.  Hardy.    The  morphology  and  distri- 
bution of  the  wandering  cells  of  mammalia.    Journ.  of  physiol.,  1894,  XVII, 
p.    81. — Altmann.     Ueber   die   Elementarorganismen  u.    ihre   Beziehurigeii 
zu  den  Zellen.     Leipzig,    1891-1894. — Muller.     Die  Morphol.   des  leukam. 
Blutes.    Centralbl.  f.  allg.  Path.,  Juli,   1894. — Barker.    On  the  presence  of 
iron  in  the  granules  of  the  eosinophile  leucocytes.     John  Hopkins  Hosp. 
Bull.,  2  oct.  1894,  n°  4. — Ligouzat.    Les  cellules  eosinoph.    These  Lyon,  1894. 
— Leonard.    Se"rie  de  photomicrographies  relatives  aux  mouvemerits  ami- 
boi'des  des  corpuscules  blancs  du  sang.    C.  R.  Acad.  Sciences,  1894,  CXIX, 
n°  4.- — Maurel.    Recherches  experimentales  sur  les  leucocytes  du  sang.    Paris, 
1894  ; — Origine  et  evolution  des  elements  figures  du   sang.     Assoc.   franc, 
p.  Vavancement  des  Sciences.,  22e  sess.,  Besangon,   1893-1894. — Kanter.    U. 
das  Vorkommen  u.  eosinoph.    Zellen  im  malignen  Lymphom  u.  bei  einigen 


54  THE    LYMPHATICS 

anderen  Lymphdriisenerkrarikungen.    Centralbl.  /.  allg.  Path.,   1894. — Siaw- 
cillo.    Cellules  eosinophiles.    Annales  de  VInstitut  Pasteur,  IX,  p.  289. — De 
Bruyne.    De  la  phagocytose  observee  sur  le  vivant  dans  les  branchies  des 
mollusques  lamellibranches.     C.   R.   Acad.   Sciences,   CXVI,   n°  2,   p.    65  ; — 
Bibl.  anat.,  1895,  n°  4. — E.  Botkine.    De  la  leucocytolyse.    Gaz.  de  Botkine, 
1895,  n08  18-19. — Semakine.    De  la  distribution  inegale  des  leucocytes  dans 
les    vaisseaux    sanguins.     Th.     Petersbourg,     1895. — Popoff.      Influence    de 
1'anesthesie  sur  la  leucocytose  et  1'aleucocytose.     Th.   Petersbourg,    1895. — 
Markevitsch.    Etude  de  la  modification  des  globules  blancs  dans  les  vaisseaux 
sanguins.     These  Petersbourg,   1895. — Gourevitch.    De  la  leucocytose.   These 
Moscou,  1895. — Borrissoff.    De  la  chimiotaxie  des  globules  blancs.    Soc.  des 
med.  russes  de  Petersb.   Vratch,  1895,  n°  18. — Messarosch.    Modif.  morphol. 
du  sang  chez  les  sujets  sains  sous  1'influence  du  chauffage  artificiel.    These 
Petersbourg,    1895. — Arnold.     Zur   Morphologie   u.    Biologie   der   Zellen   des 
Knochenmarkes.    Arch.  f.  path.  Anat.,   1895,  CXXX. — Prus.   Secretorische 
fuchsinophile  Degeneration.     Centralblatt.  f.  allgetn.  Pathol.  u.  path.  Anat., 
1895,    VI. — Marquevitsch.     Modific.    des    glob,    blancs    dans    les    vaisseaux 
sanguins.    Th.  Petersbourg,  1895. — Broi'do.   Travaux  russes  sur  la  leucocytose. 
Gaz.  hebd.  de  med.  et  de  chirurgie,   1  dec.   1895. — Demoor.    Contribution  a 
1' etude  de  la  cellule.    Individuality  f onctionnelle  du  protoplasma  et  du  noyau. 
Bull,  de  la  Soc.  beige  de  microscopie,  1893-1894,  XX,  n"s  1,  3  : — Arch.  biol., 
1895,  XXIII. — Hardy  a.  Wesbrook.     The  wandering  cells  of  the  alimentary 
canal.    Journ.  of  Phys.,  nov.  1895,  XVIII,  p.  490. — Roule.    La  phagocytose 
normale.     Revue  generale  des  Sciences,  1895,  n°  13,  p.  586. — Marschalko.    U. 
die  sogenannten  Plasmazellen.    Arch.  f.  Dermal.,   1895. — Menahen  Hodara. 
Cellules    plasmatiques    dans    les     organes    hematopoietiques    normatix    de 
1'homme  ?     Grands  mononucleaires.    Annales  Dermat.  et  Syph.,  1895,  n°  10, 
p.    856. — Siecllicki.     U.    die    Structur    u.    Kerntheilungsvorgange   bei     den 
Leukocyten  der  Urodelen.    Anzeiger  der  Akad.  der  Wissenschajt.  in  Krakau, 
avril    1895. — Chatin.     De   la   phagocytose   chez   les   huitres.     C.    R.    Acad. 
Sciences,    1896,   CXXII,  n°  8,   p.   487.— Weiss.    Hamatol.   Unters.   Pseudo- 
leukam.   als  Sammelbegriff.    Prochask.     Wien,    1896. — Valenza.   C.   R.   Soc. 
Biol.,    1890,    n°    35. — Calleja.     Distribucion   y   significacion   de   las   celulas 
abaedas  de  Ehrlich.    Rivista  trimestr.   micrografica,   1896,    1. — Gulland.     On 
the  granular  leucocytes.    Journ.  of  Phys.,  1896,  XIX,  p.  385. — Botkine.    Zur 
Morphol.  der  Blutes  u.  der  Lymphe.    Virchow's  Archiv,  1896,  CXLV,  p.  369. 
— Vassale.     Centralbl.   /.   allgemein  Path.,    1896,   IX. — Cuenot.     Amibocytes 
et  organes  lymphoi'des.    Revue  biol.,   Nancy,    13  janv.    1897  ; — Bibl.   anat., 
1897,  n°  1. — Ranvier.    Role  phys.  des  leucocytes  a  propos  des  plaies  de  la 
cornee.    C.  R.  Acad.  Sciences,   1897. — Muller  u.  Rieder.  U.  Vorkommen  u. 
klinische  Bedeutung  der  eosinoph.   Zelle  im  circulierend.  Blut  des  Menschens. 
Dent.   Aj-ch.  f.   klin.   Med.,   XL VIII. — Ribbert.     Beitrage  zur  Entzundung. 
Virch.  Arch.,  CL,  3. — Besredka.   L'etat  actuel  de  la  question  de  la  leucocytose. 
Ann.   de  VInstitut  Pasteur,    1897,   p.    726. — Przesmycki.    U.   die  intravitale- 
Farbung  des  Kernes  u.  Prot.  Biol.  Centralbl.,  XVII,  nus  9-10.—  Hirschfeld. 
Beitrage   zur   vergleichenden   Morphologie   der   Leukocyten.     Inaug.   Diss., 
Berlin,    1897. — Lceb.    U.   die  Enstehung  von  Bindegewebe  :    Leukocyten  u. 
roten  Blutkorperchen  aus  Epithel  u.  iiber  eine  Methode  isolierte  Gewebsteile 
zu  ziichten.     Chicago,  M.   Stern,    1897. — Pappenheim.    U.   Enstammung  u. 
Enstehung    der    rothen    Blutzelle.      Virch.    Arch.,    1895. — Masslow.     Einige 
Bemerkungen  zur  Morphologie  u.  Entwickelung  der  Blutelemente.    Arch.  f. 
mikrosk.  Anat.,   1897,  LI,  p.    137. — Bogdanoff.    Vorkommen  u.  Bedeutung 
der  eosinoph.  Granulat.  Biol.  Centralbl.,  1898,  CLXXXI. — Ehrlich  u.  Lazarus. 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM     55 

Die  Ancemie.  Wien,  1898. — Engel.  Leitfaden  zur  klinischen  Untersuchung. 
des  Blutes.  Berlin,  1898. — Jolly.  Recherches  sur  la  valeur  morphologique  et 
la  signification  des  differents  types  de  globules  blancs.  These  Paris,  1898. 
— Leredde  et  Bezangon.  Principales  formes  cellulaires  des  tissus  conj  one  tit's 
et  du  sang.  Presse  medic.,  1898,  p.  305. — linger.  Das  Colostrum.  Virch. 
Arch.,  1898,  CLV. — Denys.  Lymphocytes  et  myelocytes.  Presse  medicale, 
1898,  p.  118; — 5e  Congres  de  Medecine,  1899. — Klemsiewicz.  Neue  Unter- 
suclmngen  iiber  den  Ban  u.  Thatigkeit  der  Eiterzellen.  Mitteilung  des 
Vereins  der  AertzteinSteiermark,  1898. — Loevy.  Zur  Biologieder  Leukocyten. 
Virchow's  Archiv.,  1898,  CLI. — Chantemesse.  Le  globule  blanc.  Presse 
medicale,  1  dec.  1898. — Arnold.  Ueber  Struktur  u.  Architektur  der  Zellen  : 
I,  II,  III.  Archiv.  f.  mikrosk.  Anat.,  1898,  LIL— Lukjanow.  Contrib.  a 
1' etude  des  cellules  migratrices.  Arch.  Sc.  biol.,  VI,  n°  2  ; — Inst.  imp.  med. 
experim.,  Petersbourg,  fevrier  1898. — Saint-Hilaire.  Die  Wanderzelleii  in 
der  Darmwand  der  Seeeigel.  Trav.  Soc.  imp.  nat.  Petersbourg,  XXVII,  liv. 
3,  Sect.  Zool.  et  Phys. — Bettmann.  Ueber  das  Verhalten  der  eosinoph.  Zellen 
im  Hautblasen.  Munch,  med.  Woch.,  1898,  n°  39. — Cardite.  Sur  la  vie  des 
leucocytes  en  dehors  de  1'organisme.  Archivio  per  le  Scienze  mediche.  Turin, 

1898,  XXIII,  fasc.  4. — Rosa.    Pretenclus  rapports  genetiques  entre  lympho- 
cytes et  chloragogenes.    Arch.  ital.  Biol.,  4  nov.  1898,  XXX.  n°  1. — Arnold. 
Die   Farbwechsel   der   Zellgranula   insbesonders   der   acidophilen.     Centr.   /. 
allg.  Path.,  1899,  X,  n"8  21-22.—  Milchner.    U.  die  Emigration  von  Mastzellen 
bei  myelogen  Leukamie.    Zeit.  /.   klin.   Med.,    1899,  XXXVII. — Zollikofer. 
Inaug.   Diss.,   Berne,    1899. — Hausermann.     Contenance  en  fer  du  plasma 
sanguin  et  des  leucocytes.     Zeitschrift  /.  physiolog.  Chemie,  1891,  XXVI.  n°  5. 
— Kaminer.     Leucocytose   et   reaction   iodee   des   leucocytes.     Berlin,    klin. 
Wochenschrift,  7  fev.  1899. — Carriere  et  Bourneville.    Genese  des  eosinoph iles. 
Echo  medic.  Nord,  fevrier  1899. — Leredde  et  Lceper.    Equilibre  leucocytaire. 
Presse  medicale,  25  mars  1899. — Besredka.    Etude  sur  I'immunite  vis-a-vis 
des  composes  arsenicaux.     Annales  de  Vlnstitut  Pasteur,   1899,  p.  49  ; — Du 
role  des  leucocytes  dans  T intoxication  par  un  compose  arsenical  soluble. 
Ibid.,  p.  209.— Pio  Foa.  Beit,  zur  path.  Anat.  u.  zur  allgem.  Path.,  1899,  XXX, 
p.  2. — Tallquist  u.  Willebrand.    Zur  Morphologic  der  weissen  Blutkorperchen 
des  Hundes  u.  des  Kaninchens.     Skandin.  Arkiv.    /.    Phys.,  X,  72,  p.   37. 
— Sicherer.    Zur  Chemiotaxie  der  Leukocyten  in  vitro.  Centralblatt  f.  Bakt., 
XXVI,  ii"s  11,  12,  p,  360. — J.  Arnold.   U.  Granulafarbung  lebender  u.  uberle- 
bender  Leukocyten.    Virchow's  Arch.,  1899,  p.  425. — Salmon.    Glycogene  et 
ieucocj^tes.     Th.   Paris,    1899. — Pappenheim.     Vergleich.     Untersuch.  u.   die 
elementare    Zusammensetzung   des   rothen   Knochenmarkes   einiger   Sauge- 
thiere  ;    Bemerkungeii   zur   Frage   des   gegenartigen   Verhaltnisse   der   vers- 
chiedenen    Leukocyten-Formen    zu    einander.     Archiv.    f.    pathol.    Anat.    u. 
Phys.,   CLVII,   I. — Haj^em.     Mononucleaires  du  sang  humain.     C.   R.   Soc. 
Biol.,  1899,  p.  283  ; — De  1' infiltration  granuleuse  des  globules  polynucleaires. 
C.  E.  Soc.  Biol.,  1899,  p.  434  ; — Leucocytes  du  sang  de  cheval.    C.  R.  Soc. 
Biol.,  1899,  p.  623  ; — Leucocytes  de  la  lymphe  de  cheval.    C.  JR.  Soc.  Biol.t 

1899,  p.   621. — Jolly.    Leucocytes  granuleux  du  sang  humain.     G.  P.   Soc. 
Biol,   1899,  p.   140.— Franca  et  Athias.    C.  R.  Soc.  Biol.,   1899,  p.   317.— 
Malassez.     Representation    graphique    du    nombre    des    leucocytes.     C.    R. 
Soc.  Biol.,   1699,  p.   181. — Dominici.    Origine  des  leucocytes  polynucleaires 
du  lapin.    C.  R.  Soc.  Biol.,  1899,  p.  168.— Achalme.    C.  R.  Soc.  Biol.,  1899. 
— Brandenburg.     La   reaction   des   leucocytes   avec   la   teinture   de   gai'ac. 
Miinchen.  medicin.  Wochensch.,  1900.  n°  6,  p.  183. — Ranvier.    Des  clasmato- 
cytes.   Archiv.  $  Anat.  microscop.,  15  mars  1900. — Grunwald.   Die  Bedeutung 


56  THE    LYMPHATICS 

der  hypeosinophilen  Gramila.  Centralbl.  f.  innere  Med.,  1900.  n°  14,  p.  345. 
— Bettmann.    Volkmann's  Sammlung  klin.  Vortrdge,  1900,  11°  266. — Zabolonty. 
Ferment  amylolytique  des  globules  blancs  du  sang.     Roussk.  Arkh.  PatoL, 
klin.  Med.  i  BakterioL,  avril  1900. — Cabot.    A  guide  to  the  clinical  examination 
of    the  blood,  London,    1900. — Michaelis.    Berlin,  med.   Gesettschaft,   24     oct. 
1900; — Deut.  med.  Woch.,  1900. — Jolly.  Clasmatocytes  et  Mastziellen.    C.R. 
Soc.Biol.,23  juin  1900. — Stassano  et  Hass.     Contribution  a  la  physiol.  des 
clasmatocytes,  C.  R.  Soc.  BioL,  1900. — Tarchetti.    Ferment  diastasique  dans 
les  globules  blancs.    Gaz.  degli  Osped.,  29  juillet  1900. — Laguesse.    La  classi- 
fication des  leucocytes.    Echo  medic,  du  Nord,  1900,  IV,  n°  32,  p.   359.—  Hof- 
bauer.    Leucocytes  iodophiles.    Centralblattf.  innere  Med.,  1300,  11°  6. — Domi- 
nici.  Elements  figures  du  sang;  teur  morphologic.  Pressemedicale,  ISaout  1900. 
— Arnozan  et  Montel.    Role  des  leucocytes  dans  1' absorption  des  medicaments. 
Congres  Paris,  aout  1900. — Dominici.  Eosinophilie.  C.  R.  Soc.  BioL,  20  Janvier 
1900. — Rouget.  Phagocytose  et  leucocytes  hematophages.   C.  R.  Soc.  BioL,  31 
mars  1900. — Besredka.    Leucotoxine.    Annales  de  VInstitut  Pasteur,  25  juin 
1900. — Jolly.    Kaiyokinese  des  globules  blancs  dans  la  lymphe  peritoneale 
du  rat.   C.  R.  Soc.  BioL,  21  juillet  1900. — Dumont.  Formule  hemoleucocytaire 
normale.     Extr.    des   Annales   de   la   Policlinique   de   Lille,    1900. — Hayem. 
Lecons  sur  les  maladies  du  sang,  1900. — F.  Muller.   U.  einige  pathol.   Bef uncle 
bei  der  Ricinvergift.    Ziegler's  Beitr.,   1900,  XXVII. — Levaditi.    Un  cas  de 
leucemie  myelogene.    Consid.  sur  la  mastzellen-leucocytose  et  sur  I'hetero- 
chromatie  des  granulations  leucocytaires.    Journ.  Phys.  et  Path,  gen.,  1901. 
— Lombard.    Contrib.  a  la  phys.  des  leucocytes.      C.  R.  Soc.  BioL,  mai  1901. 
— Michaelis  et  Wolff.    Deut.  med.   Woch.,  10  sept.   1901. — Hirschfeld.    Berl. 
klin.  Woch.,  7  oct.  1901. — Bonne.    Leucocytose  eosinoph.  avec  essaimage  de 
granul.  dans  le  voisinage  d'une  glande  en  suractivite.    C.  R.  Soc.  BioL,  4  mai 
1901. — Jolly.    Sur  quelques  points  de  la  morphologie  des  leucocytes.    C.  R. 
Soc.    BioL,    8   juin    1901. — Stassano.     Acad.    des   Sciences,    4   mars    1901. — 
Stassano  et  P.  Bourcet.    Sur  la  presence  et  la  localisation  de  1'iodedans  les 
leucocytes  du  sang  normal.    Ac.  Sciences,  24  juin  1901. — Brodie.    On  the 
clestruct.  of  leucocytes.    Journ.  of  Anat.  a.  Phys.,  1901,  XXXV  ; — N.  ser., 
XV. — Williams.    Boston  med.  Journ.,  sept.  1901. — Birri.     Sulla  nature  e  s. 
signif.   delle  granulazioni  iodofile  e  di  quelle  eosinopile    nei    leucociti.     II 
Policlinico,    1901,    VIII,    p.    299. — Grunberg.     Beitrage   zur   vergleichenden 
Morphologie  der  Leucocyten.    Arch.  /.  Path.  u.  Phys.u.  f.  klin.  M ed. ,  CLXIII 
(Folge  16,  Bd  III),  2,  p.   303.— Poijakoff,  Zur  Frage  von  der  Enstehung, 
clem  Bau  u.  der  Lebensthatigkeit  des  Blutes.    Arch.  /.  Anat.  u.  Phys.,  1901  : 
Anat.    Abth.,    1. — Wolff.     Ueber   die   act.    Beweglichkeit   d.    Lymphocyten. 
Berlin,  klin.  Woch.,  30  dec.  1901. — Dominici.  Arch.  Med.  exp.  etd'  Anat.  path. , 
1901-1902. — Levaditi.  Contrib.  a  1'etude  des Mastzellen,  etc.  TheseParis,  1902. 

THE    LYMPHATIC    VESSELS. 

HISTORICAL. — Aristotle  (384-322  B.C.),  as  is  evident  from  a  phrase  in  the 
History  of  Animals,  appears  to  have  seen  lymphatic  vessels  ;  but  it  is  to 
Herophilus  (300  B.C.)  and  to  Herasistratus  (280  B.C.)  to  whom  we  ought, 
according  to  the  Galenic  writings,  to  attribute  the  discovery  of  the  chyliferous 
vessels.  Herasistratus  saw  their  milky  contents ;  Herophilus  their  termination 
in  the  mesenteric  glands.  The  former  regarded  them  as  arteries,  the  latter 
as  veins.  These  observations,  which  were  denied  by  Galen,  were  forgotten, 
and  it  was  only  in  1532,  that  Nicolas  Massa  apparently  discovered  some 
renal  lymphatics.  Then  Fallopius  discovered  some  white  vessels  which 
terminated  in  the  peripancreatic  glands. 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM  57 

In  1563,  Eustachius  discovered  the  thoracic  duct  in  the  horse,  and  described  it 
under  the  name  of  vena  alba  thoracis  as  follows:  "  From  the  trunk  of  the 
left  subclavian  vein  stretches  a  prolongation  which  is  full  of  aqueous  humour 
and  which  divides  near  its  origin  into  two  branches,  which  soon  reunite  to 
constitute  a  single  trunk  ;  the  latter  passes  along  the  left  side  of  the  spinal 
column,  traverses  the  diaphragm,  arrives  nearly  to  the  centre  of  the  lumbar 
region,  where  it  enlarges,  and  surrounding  the  aorta  becomes  lost,  presenting 
a  mode  of  termination  which  hitherto  has  not  been  recognized."  Eustachius 
therefore  saw  the  inferior  "enlargement"  of  the  thoracic  duct.  Should  this 
justify  us  in  attributing  to  him,  together  with  Winslow  (The  Anatomical 
Exposition  of  the  Structure  of  the  Human  Body,  MDCCLXI),  the  discovery  of  the 
cistern  of  Pecquet  ? 

The  right  lymphatic  duct  was  discovered  by  Stenon. 

In  1622,  Aselli  made  a  new  discovery,  viz.,  the  existence  of  chyliferous  vessels. 
Seeing  them  in  the  dog,  the  cat,  the  lamb,  the  cow,  the  pig,  and  the  horse, 
he  noticed  that  they  joined  the  mesenteric  glands,  and  he  imagined  that  they 
terminated  in  the  liver.  It  fell  to  Pecquet  (1649)  to  demonstrate  their 
confluence  at  the  swollen  commencement  of  the  thoracic  duct,  to  which  he 
gave  the  name  of  cistern  or  reservoir  of  the  chyle. 

But,  as  Galen  had  denied  the  existence  of  the  canals  of  Herasistratus  and 
Herophilus,  so  Riolan  and  Harvey  denied  the  presence  of  the  lacteal  veins 
of  Aselli.  To  definitely  prove  their  existence,  the  works  of  Gassendi  (1628), 
Vessling  (1634),  Folius  and  Tulpius  (1639),  Wallee  (1641),  and  Pecquet 
(1649),  were  necessary. 

Vessling  and  Rudbeck  then  described  the  lymphatics  of  the  liver,  the 
pancreas,  the  lungs,  and  the  pelvis.  Rudbeck  concluded  from  his 
researches  that  "  the  serous  vessels  "  exist  not  only  in  the  mesentery,  but 
throughout  the  organism,  or  that  they  form  a  special  system.  Bartholin 
and  Jolyff  did  not  delay  matters  by  confirming  this  attempt  at  generaliza- 
tion, and  the  serous  system  of  Rudbeck  soon  became  the  lympJiatic  system. 
This  substitution  of  purely  verbal  terms,  resulted  in  Bartholin  being  regarded 
as  the  author  who  first  attempted  to  systematize  the  white  vessels.  As  a  result 
of  this  new  and  wider  conception  of  the  scope  of  general  anatomy,  works  on 
the  subject  then  began  to  increase,  and  became  so  numerous  that  it  is  impos- 
sible for  us  even  to  mention  them  all  here. 

After  Rudbeck,  Bartholin,  Swammerdam  and  Blasius,  Ruysch  in  1665, 
studied  the  valves,  and  compared  their  shape  to  that  of  the  crescent  of 
the  moon.  Afterwards,  Nuck,  R.  Hale,  Meckel,  Haller  and  Cruickshanks  dis- 
covered new  lymphatics  in  regions  which  had  hitherto  not  been  examined. 
Hunter  found  white  vessels  in  the  intima,  and  laid  great  stress  on  the  im- 
portant part  played  by  the  lymphatic  system  in  the  process  of  absorption. 

Hewson  studied  the  lymphatics  in  fishes.  In  mammals  he  thought  that 
some  of  the  vessels  entered  the  thoracic  duct  without  traversing  the  glands. 
Mascagni,  the  author  of  an  admirable  ichnograph,  demonstrated  the 
incorrectness  of  this  idea.  With  Haller  and  Cruickshanks,  he  rejected,  in 
opposition  to  Stenon,  Wepper,  Schmiedel,  Bcerhave,  Bartholin,  and  Meckel, 
the  view  that  there  is  any  peripheral  communication  between  the  lymphatic 
and  blood  systems.  According  to  him,  communications  with  the  white 
vessels  take  place  in  the  connective  tissue,  for  it  is  in  their  meshes 
that  they  originate.  It  so  happened  that  Mascagni  was  singularly  fortunate, 
for  his  views  were  adopted  and  generalized  by  Bichat,  who  admitted  the 
presence  of  lymphatic  openings,  not  only  in  the  connective  tissue,  and  in 
serous  surfaces,  but  also  in  membranous  coverings  (pores  of  Haase). 


58  THE    LYMPHATICS 

This  splendid  anatomist  remarked  that  "the  lymphatic  system  essentially 
enters  into  the  formation  of  the  serous  membranes".;  he  must  regard  the 
serous  membranes  "  as  large  reservoirs  intermediate  between  the  exhalent  and 
absorbent,  where  the  lymph  in  going  from  one,  remains  some  time  before  pass- 
ing into  the  other,  and  where  it  doubtless  undergoes  various  preparations." 

Some  years  later,  Lippi  (1822)  and  Lauth  (1824)  discovered  the  existence 
of  peripheral  lymphatico-venous  communications ;  further,  Lauth  established 
the  fact  that  each  lymphatic  had  its  origin  in  a  network. 

Ever  since  1832,  important  works  in  comparative  anatomy  by  Muller, 
Panizza  and  Fohmann  have  appeared.  Jean  Muller  discovered  the  posterior 
lymphatic  heart  of  the  frog.  Panizza  discovered  the  lymphatic  hearts  of  the 
ringed  adder  and  the  frog.  He  considered  them  analogous  to  the  supraval- 
vular  enlargements  of  the  lymphatic  trunks  of  mammals.  These  organs 
have  been  described  in  some  birds  by  Panizza,  Fohmann,  and  subsequently 
by  Stannius  and  Gadow.  They  think  these  hearts  communicate  with  the 
veins.  Fohmann,  who,  in  opposition  to  Panizza,  regarded  the  lymphatic 
hearts  as  rudimentary  glands,  admitted  with  Tiedmann  and  Louth  the 
existence  of  lymphatico-venous  communications  in  the  interior  of  the  gland. 

Rusconi  described  the  peri  vascular  lymphatic  sheaths  of  the  frog  as  a 
simple  "  muff  "  in  whose  lymph,  the  blood-vessels  are  bathed.  Later  on, 
Milne-Edwards  compared  them  to  the  visceral  serous  membranes  of  mammals, 
and  Ranvier  demonstrated  their  double  endothelium. 

In  1847,  Sappey  commenced  a  long  series  of  researches,  which  he  continued 
until  the  publication  of  his  large  atlas  in  1876.  Though  the  descriptions  con- 
tained therein,  which  have  now  become  classical,  only  leave  to  modern  in- 
vestigators a  restricted  field  of  inquiry,  it  cannot  be  said  that  his  attempts 
at  general  anatomy  were  so  successful.  In  opposition  to  Mascagni,  he 
maintains  that  "  a  fair  number  of  the  constituent  parts  of  the  body,  viz.  the 
nervous  system,  the  heart  and  vessels,  the  mucous  surfaces  of  the  bladder, 
the  ureters,  the  serous  surfaces,  and  the  connective  tissue — elastic  and  bony,  are 
absolutely  and  habitually  destitute  of  lymphatic  vessels."  Further,  he  also 
considered  that  the  white  vessels  take  origin  from  a  double  network  of  capil- 
laries and  lacunae  which  are  absolutely  closed.  Hitherto,  problems  for  dis- 
cussion had  been  solved  almost  entirely  by  the  sole  aid  of  micro- 
scopic anatomy.  Virchow,  in  1857,  was  the  first  to  bring  histological 
methods  to  bear  on  the  long  discussed  question  of  the  origin  of  lym- 
phatics. An  optical  error  made  him  describe  the  connective  tissue  cell, 
the  plasmatic  cell,  as  star-shaped,  hollow,  and  anastomosing  by  its  prolonga- 
tions with  neighbouring  cells.  He  thought  that  in  the  plasmatic  system, 
which  is  formed  by  a  collection  of  such  cells,  circulated  the  plasma,  which 
gave  origin  to  the  lymphatic  system.  Koelliker,  who  in  1846,  had  seen  in 
the  tail  of  the  tadpole,  lymphatics  in  process  of  development,  thought  that 
their  hollow  terminal  point  was  continuous  with  the  prolongations  of  neigh- 
bouring connective  tissue-cells.  He,  as  did  Leydig,  also  regarded  this  as 
a  new  proof  in  support  of  Virchow's  theory,  which  was  opposed  by  Henle, 
and  long  since  abandoned  by  Ludwig  and  Briicke,  who  were  the  first  to  revert 
to  the  opinions  of  Mascagni  and  Bichat. 

Recklinghausen,  who  discovered  the  lymphatic  endothelium,  believed 
also  in  the  existence  of  plasmatic  canals.  These  "  canals  of  the  juice  " 
(Saftkanalchen),  have  a  wall  of  their  own ;  they  anastomose  with  each  other  ; 
they  also  form  cross- junctions,  in  the  interior  of  which  is  found  a  cell  com- 
posed of  a  mass  of  protoplasm.  The  same  scientist  demonstrated  by  a  well 
known  experiment,  the  existence  of  communications  between  the  lymphatic 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM  59 

system  and  the  serous  cavities,  the  existence  of  which  had  previously  been 
admitted  by  Bichat.  This  experiment,  repeated  and  varied  by  Ludwig, 
Schweigger-Seidel,  Dogiel,  Dybkowsky,  Wagner,  Oedmanson,  compelled  us 
to  admit  the  existence  of  wide  orifices,  which  are  always  open,  and  which  are 
situated  between  the  serous  and  the  lymphatic  cavities.  This  conclusicn 
was  invalidated  by  the  histological  researches  of  Ranvier  (1873),  Hermann 
and  of  Tourneaux  (1874).  Ranvier  believed  in  the  existence  of  a  kind  of 
valve  with  mobile  lips,  which  was  capable  of  being  widened  by  the  lymphatic 
cells.  Hermann  and  Tourneaux,  whose  views  were  confirmed  by  Bizzozero 
and  Salvioli,  denied  the  existence  of  these  orifices,  and  thought  that  similar 
appearances  were  caused  in  places  where  the  endothelium  was  in  process  of 
renewal. 

In  1874,  Arnold,  again  upheld  the  existence  of  peripheral  communications 
between  the  lymphatics,  the  blood-vessels,  and  the  connective  tissue-cells. 
Tarchanoff  (1875)  showed  that  simple  appearances  might  be  deceptive. 

Histological  researches  soon  afforded  valuable  information  regarding  the 
structure  of  lymphatic  channels  of  all  kinds  (Recklinghausen,  Ranvier,  Renaut, 
etc.),  but  it  was  long  before  they  were  the  means  of  solving  the  much  vexed 
question  as  to  the  real  origin  of  the  white  vessels.  It  was  only  in  1893,  and 
1894,  that  Renaut,  Regant  and  Ranvier  definitely  settled  this  question  by 
showing,  in  accordance  with  the  old  opinions  held  by  Belajeff,  Dybrowsky, 
Cohnheim,  Robin  and  Hoggari,  that  all  lymphatics  commence  in  a  closed 
ampulla. 

Ranvier  (1895),  studied  the  development,  the  involution,  and  the  con- 
fluence of  the  lymphatic  vessels.  He  concluded  that  the  lymphatic  system 
resembled  a  large  vascular  gland  which,  originating  from  the  veins,  poured 
into  these  vessels  the  product  of  its  secretion,  the  lymph.  Sala,  following 
Budge,  traced  the  formation  of  the  lymphatic  hearts  and  of  the  thoracic  duct  in 
the  fowl.  The  thoracic  duct,  he  regards  as  a  mesenchymatous  formation, 
which  is  at  first  absolutely  independent  of  the  venous  system. 

Kytmanoff  (June  1901),  applied  Ehrlich's  method  to  the  discovery  of  the 
nerves  of  lymphatic  vessels,  a  research  which  had  already  been  undertaken 
by  Timofejew,  Dogiel,  Smirnow,  Weliki,  Quenu  and  Darier. 

TECHNICAL  METHODS. — Though  the  thoracic  duct  and  chyliferous  vessels 
may  be  seen  without  previous  preparation,  the  study  of  the  other  lym- 
phatics necessitates  the  employment  of  methods  which  render  them  distinct, 
either  by  distending  their  cavities,  or  shewing  their  endothelial  outline. 
The  methods  of  descriptive  anatomy,  were  confined  to  causing  dis- 
tension of  the  vascular  wall,  which  was  usually  effected  by  placing  an  obstacle 
in  the  current  of  the  lymph,  together  with  the  injection  of  some  foreign  sub- 
stance. 

To  discover  the  white  vessels  of  the  lung,  Willis  stopped  the  flow 
of  lymph,  by  placing  a  ligature  on  the  superior  extremity  of  the  thoracic  duct. 
With  the  same  object,  Ruysch  and  Cruikshanks  ligatured  the  blood-vessels 
of  the  kidnej'  in  order  to  see  its  lymphatics. 

By  this  method,  the  injection  was  made  either  directly  into  an  artery,  or  in  a 
haphazard  way  into  the  cellular  tissue.  The  injection  of  lymphatics  by 
means  of  the  blood-system  which  was  known  to  Mascagni  and  Meckel,  is  less 
in  vogue  to-day  than  interstitial  injection,  on  account  of  the  substances 
which  were  used. 

It  would  be  difficult  to  mention  all  the  substances  which  have  been  tried, 
since  the  time  of  Swammerdann  and  Ruysch.  To  show  their  diversity  we 
need  only  mention,  water,  gelatine,  wax,  oil,  Chinese  ink,  Prussian  blue, 


60  THE    LYMPHATICS 

carmine  in  solution  or  in  suspension,  mercury,  and  even  microbic  cultures. 
Though  Sappey  was  able  to  see  the  deep  lymphatics  of  the  kidney  by  using 
water,  this  fluid  is  not  much  employed  now.  Chinese  ink,  microbes,  and 
coloured  gelatine,  are  especially  adapted  for  histological  work,  though  for 
macroscopical  study  mercury,  used  according  to  Meckel's  method,  and  per- 
fected, by  Sappey,  or  the  colouring  matters  used  in  Gerota's  and  Boddaert's 
method  are  used  in  preference. 

SAPPEY'S  METHOD. — First  of  all  an  adult  subject,  and  one  as  thin  as  possible, 
should  be  selected.  If  putrefaction  is  so  advanced  that  the  skin  is  green, 
and  the  epidermis  raised  in  large  flakes,  the  injection  of  the  cutaneous 
lymphatics  is  favoured,  but  that  of  the  collecting  trunks  is  hindered,  while 
the  study  of  the  submucous  and  subserous  vessels  becomes  impossible.  The 
apparatus  required  for  the  injection  of  more  than  120  centimetres,  consists 
essentially  of  two  tubes.  One  of  these  is  made  of  glass  arid  furnished  at  either 
extremity  with  a  metal  covering  ;  at  its  upper  end  is  a  movable  eye,  by 
which  it  is  suspended  from  a  smooth  pulley,  which  is  attached  to  a  horizontal 
bar  of  iron.  To  its  inferior  extremity  is  fixed  a  flexible  tube,  which  is  made 
of  vulcanized  caoutchouc,  with  very  thick  walls,  but  with  a  very  small  calibre. 
To  the  free  extremity  of  the  flexible  tube  is  fitted  a  stopcock  and  a  hollow 
adjustment  with  a  screw  thread  ;  the  glass  tube,  which  has  been  drawn  out 
in  the  flame  to  a  fine  point  for  puncturing  the  tissues,  is  introduced  into  the 
adjustment  at  its  larger  end,  which  has  previously  been  wrapped  round  with 
waxed  threads.  The  point  of  the  glass  tube  must  penetrate  the  superficial  layer 
of  the  skin,  and  be  worked  under  a  thickness  of  2-3  millimetres.  The  index 
finger  of  the  right  hand  then  turns  the  stopcock  from  right  to  left.  If  suc- 
cessful, the  mercury  fills  the  lymphatic  network.  After  half  a  minute  or  at 
the  most  a  minute,  the  tube  is  withdrawn,  for,  if  it  remains  in  longer,  there 
is  a  risk  of  rupture.  It  often  happens  that  though  the  lymphatic  plexus  is 
injected,  the  mercury  does  not  penetrate  into  the  trunks  and  reach 
the  glands.  In  this  case  we  must  inject  the  vessel  directly,  after  placing  a 
ligature  below  the  point  at  which  it  is  proposed  to  penetrate  it.  To  effect 
this,  Sappey  gently  depressed  the  wall  and  quickly  made  a  puncture  into  the 
concavity  thus  formed. 

It  goes  without  saying  that  the  injection,  should  always  be  made  in  the 
direction  of  the  current  of  the  lymph. 

After  the  completion  of  the  injection,  the  connective  tissue  which  surrounds 
the  lymphatic  vessels  should  be  left  undisturbed,  for  if  a  minute  dissection 
is  now  attempted,  there  is  a  great  risk  that  these  vessels  will  be  injured, 
whereas  if  allowed  to  dry  the  connective  tissue  will  become  transparent  and 
enable  us  to  see  these  vessels  shining  through.  During  the  drying  process 
the  parts  should  be  kept  in  the  horizontal  position. 

GEROTA'S  METHOD. — This  author  conceived  the  idea  of  using  absolute  black, 
extractum  alkanae,  cinnabar  and  Prussian  blue.  The  extractum  alkanae! 
whose  colouring  power  is  somewhat  feeble,  diffuses  and  stains  the  fat.  The 
cinnabar,  which  is  ground  in  linseed  oil  and  chloroform,  is  only  slightly 
penetrating.  The  Prussian  blue  succeeds  the  best.  Its  preparation  is  for 
the  most  part  very  simple,  and  is  as  follows;  2  grammes  of  Prussian  blue 
kept  in  tin-foil  tubes  are  taken,  to  which  3  grammes  of  pure  spirit  of  tur- 
pentine are  added  ;  after  the  whole  has  been  well  rubbed  down  in  a  china 
mortar,  15  grammes  of  sulphuric  ether  are  added,  and  filtered  through  a 
double  layer  of  linen.  The  solution  must  be  used  at  once  for  injection. 
The  injection  is  made  with  a  syringe,  which  holds  from  10-20  cubic  centi- 
metres, at  the  end  of  which  is  fixed  a  small  adjustment  which  receives  the 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM    61 

glass  needle  for  puncturing  the  tissues.  To  prevent  leakage,  the  larger  ex- 
tremity of  the  glass  needle  is  wrapped  round  with  a  waxed  thread.  The 
point  is  drawn  out  in  the  flame.  It  must  not  be  too  fine  nor  too  thick. 

Though  Gerota's  method  may  yield  less  beautiful  preparations  than  those 
furnished  by  mercurial  injections,  it  has  a  great  many  advantages  from  a  re- 
search point  of  view.  Without  laying  undue  stress  on  the  simplicity  of  the 
technique,  and  the  cheapness  of  the  preparation,  we  may  observe  that  it  defines 
lymphatic  territories  much  better  than  does  mercury.  This  difference 
between  the  two  methods  exists  for  the  following  reasons.  Mercury  often 
yields  extended  injections  of  networks,  and  always  forcibly  distends  the 
vessels  with  very  fine  walls,  of  which  the  latter  are  composed,  but  the 
collecting  trunks  being  more  resistant,  dilate  less.  The  latter,  therefore,  are 
not  easily  to  be  distinguished  from  their  plexus  of  origin.  Now  Gerota's 
mixture,  which  is  always  injected  under  low  pressure,  usually  gives  a  limited 
injection  of  the  plexus,  and  leaves  to  the  collecting  trunks  their  preponder- 
ance in  volume  ;  the  result  is  that  the  latter  are  always  well  seen,  and  the 
limits  of  their  boundaries  are  clearly  marked.  The  possibility  of  injecting 
different  systems  of  collecting  trunks  with  different  colouring  materials, 
almost  enables  us  to  reduce  to  a  system  the  mapping  out  of  the  different 
territories.  Another  advantage  this  method  possesses  is,  that  it  enables  us 
to  study  histology. 

The  fact  is  that  microscopical  anatomy  utilizes  methods,  not  only  capable 
of  shewing  endothelium,  but  also  methods  whereby  the  vascular  cavity  is 
distended  by  coloured  substances,  or  substances  easily  recognizable  by  their 
histo-chemical  reactions.  This  result  is  obtained  by  injection,  physiological 
absorption,  or  imbibition. 

The  injection  may  be  made  either  into  the  dead  or  the  living  subject. 
Coloured  substances,  injected  into  the  cadaver,  are  used  for  the  study 
of  blood-vessels.  They  should  have  the  following  qualities:  they  should  be 
of  easy  penetration,  homogeneous,  transparent,  and  indiffusible.  The  more 
satisfactory  are  carmine  substances  and  the  soluble  Prussian  blues  recom- 
mended by  Ranvier.  As  Prussian  blue  does  not  diffuse  in  aqueous  solution, 
the  employment  of  gelatine,  which  by  its  rapid  solidification  always  com- 
plicates the  operation,  can  be  avoided.  Other  vehicles,  such  as  collodion, 
albumin,  and  glycerine  yield  indifferent  or  bad  results. 

Though  it  has  been  known  for  some  time  that  the  lymphatic  vessels 
possess  an  absorbing  power,  it  is  only  in  recent  years  that  a  procedure 
known  as  vital  injection,  which  is  based  on  this  fact,  has  been  methodically 
practised.  Whereas  Boddaert  injects  fluorescine,  and  D'Abundo  and 
Guillain,  Chinese  ink,  Albarran  and  subsequently  Homen  and  Laitinen 
inoculate  microbes. 

Though  it  is  well  known  that  certain  microbes  under  conditions  as  yet 
imperfectly  understood,  exercise  a  remarkable  selective  power  in  follow- 
ing their  lymph  channels,  and  thus  yield  marvellous  injections,  we  cannot 
disguise  from  ourselves  the  fact  that  such  cases  are  somewhat  rare,  and 
their  explanation  baffles  us  completely.  It  is  difficult  to  make  certain  of 
obtaining  a  pure  lymphatic  injection,  and  to  diminish  the  vitality  and  the 
natural  mobility  of  microbes  which,  as  Guillain  has  justly  observed,  can 
create  lesions  by  themselves  or  by  the  toxins  to  which  they  give  rise,  or 
which  may  invade  the  circulatory  system. 

There  is  another  method,  based  on  the  physiological  absorption  of  fats 
by  the  intestinal  lymphatics,  which  enables  us  to  trace  the  latter  in  sections 
previously  treated  with  osmic  acid. 


62  THE    LYMPHATICS 

Altmann  observed  that  when  any  tissue  whatsoever  imbibes  fat,  the  lympha- 
tics especially  become  impregnated  with  it.  To  bring  into  view  the  lymphatic 
network,  he  stains  the  fatty  part  of  the  body  black  with  osmium,  and  destroys 
the  other  parts  of  the  organism  by  corrosion.  He  immerses  the  fresh  tissue 
in  a  mixture  of  oil  and  absolute  alcohol,  and  keeps  it  in  this  liquid  for  five 
days  ;  the  parts  are  then  washed  for  three  or  four  hours  in  distilled  water  ; 
this  removes  the  superficial  fat,  and  precipitates  that  which  has  penetrated 
into  the  lymphatic  channels  by  imbibition  ;  it  is  then  placed  for  twenty-four 
hours  in  a  solution  of  osmic  acid  (1  in  100),  then  submitted  to  slow  corro- 
sion in  bleaching  liquid  diluted  with  three  times  its  volume  of  water.  We  may 
actually  dispense,  as  we  have  done,  with  the  corrosion,  and  rapidly  dehy- 
drate with  absolute  alcohol  and  xylol.  By  this  method,  the  contents  of  the 
vessels  alone  are  coloured  black,  and  stand  out  clearly  on  the  red-brown  back  - 
ground  of  the  preparation. 

There  are  several  methods  used  for  demonstrating  endothelium,  but 
they  all  reduce  themselves  to  impregjwtion,  obtained  by  a  metallic 
salt,  or  an  anilin  colour,  such  as  methylene  blue.  The  silver  salts  are  more 
used  than  the  salts  of  gold  (Hoggan's  method  with  chloride  of  gold).  Of  all 
the  silver  salts  which  have  been  suggested,  viz.  picrate,  acetate,  lactate, 
(Alferow),  nitrate  (Recklinghausen),  the  latter,  which  is  the  oldest,  is  most 
widely  used. 

Aqueous  solutions  varying  from  1  in  300  to  1  in  1,000  are  sometimes  used  ; 
sometimes  gelatin  (Malassez  or  picric  or  osmic  acid  (Renaut)  is  added. 

The  rectified  methylene  blue  of  Ehrlich  (Griibler)  and  of  Merck  has  yielded 
in  the  hands  of  Dogiel  and  Mayer  exceedingly  beautiful  endothelial  im- 
pregnations. 


THE  ARRANGEMENT  AND  GENERAL  CHARACTERISTICS 
OF  LYMPHATIC  VESSELS 

Originating  in  the  meshes  of  the  connective  tissue,  the  white 
vessels,  that  is  to  say,  the  lymph  passages,  which  are  provided  ivith  a 
wall  of  their  oivn,  anastomose  and  form  rich  peripheral  plexuses 
(the  original  capillary  networks  of  Lauth,  Fohmann,  and  Panizza). 
They  then  decrease  in  number  and  reach  the  glands,  in  which  they 
again  break  up  into  capillaries.  After  traversing  the  glands,  they  pass 
into  the  large  collecting  trunks,  viz.  the  thoracic  duct  and  the  right 
lymphatic  duct,  by  means  of  which  the  lymph  is  conducted  into 
the  subclavian  veins.  Thus  in  each  gland, a  true  portal  lymphatic  system 
exists,  and,  regarded  as  a  whole,  this  vast  system  of  branching  lym- 
phatics constitutes  a  cone-shaped  figure  whose  central  apex  rests 
on  the  venous  system. 

CAPACITY. — At  their  commencement,  i.e.  at  the  base  of  the  cone, 
the  lymphatics  have  a  capacity  equal  to,  and  greater  than,  that 
of  the  veins.  This  diminishes  the  nearer  we  approach  the  thoracic 
duct,  the  calibre  of  which  is  much  smaller  than  that  of  the  vena-cava. 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM  63 


In  distinction  to  the  veins,   the  lymphatics  diminish  in  number 
without  proportionately  increasing  in  calibre. 

COLOUR. — If  observed  intact  in  the  cadaver,  or  better  still  in 
the  living  animal,  the  milky  whiteness  of  the  contained  lymph  can 
be  seen  through  their  fine  fragile  walls  ;  the  name,  lacteal  veins, 
given  by  Aselli,  exactly  expresses  this  appearance. 

FORM. — The  lymphatics  are  sometimes  cylindrical,  sometimes 
moniliform,  and  again,  may  resemble  sacs  or  crevices.  The  varia- 
tions in  their  structure,  and  the  different  texture  of  tissues 
traversed,  explains  this  polymorphism.  It  is  only  when  they 
possess  valves  that  they  present  that  series  of  alternate  swellings 
and  constrictions  to  which  they  owe  their  characteristic  resemblance 
to  chaplets.  In  their  course  through  the  viscera,  they  are  cylindrical. 
To  this  rule,  which  was  enunciated  by  Sappey,  there  are  numerous 
exceptions.  In  reality,  their  form  varies  according  to  whether  they 
are  isolated  in  a  closely  set,  dense,  connective  tissue,  or  whether 
they  are  numerous  and  situated  close  together,  in  a  lax  connective 
tissue.  If  constricted  by  fascial  aponeuroses,  such  as  those  in  the 
centre  of  the  diaphragm  for  example,  they  are  reduced  to  mere 
crevices,  but  in  the  meshes  of  a  lax  connective  tissue  they  dilate 
to  their  maximum  capacity,  anastomose,  and  tend  to  run  together. 
Sometimes  they  are  sinuous  or  sacciform  ;  thus  by  their  irregularity, 
they  form  typical  plexuses. 

VALVES. — These  do  not  exist  throughout  the  whole  extent  of  the 
lymphatic  vessels  ;  they 
are  absent  at  their  com- 
mencement, and  in  the 
capillaries,  and  are  rare 
in  the  large  collecting 
trunks  (thoracic  duct). 
Sappey  has  counted,  from 
60  to  80  in  the  vessels 
extending  from  the  fingers 
to  the  axillary  glands,  and 
from  80  to  100  in  the 
lower  limb.  At  first  the 
valves  are  only  a  few 
millimetres  apart  from 
each  other,  but  in  the 
thoracic  duct  they  are 
separated,  by  intervals 


FIG.  10.  —  Valves  of  the  mesenteric  chyliferous  vessels 
of  the  new  born  cat  (picro-osmic  mixture,  Verick 
oc.  2  obj.  o).  Xotice  the  fineness  of  some  of  the 
anastomotic  branches. 


varying    from     6    to     10    centimetres, 


64  THE    LYMPHATICS 

and  sometimes  more.  They  are  arranged  in  pairs,  and  resemble  the 
aortic  semi-lunar  valves,  but  do  not  always  present  at  their  free  bor- 
der a  nodule  comparable  to  the  corpora  Aurantii.  The  position  of 
these  valves  is  variable,  since  even  in  the  same  vessel,  at  one  time 
we  see  their  face,  at  another,  their  profile ;  and  sometimes  again  we 
may  see  them  occupying  intermediate  positions  (Ranvier).  Some- 
what resembling  a  crescent,  their  free  border  is  turned  towards  the 
heart ;  their  adherent  convex  edge  corresponds  to  the  constriction 
in  the  vascular  wall.  Immediately  above  this,  their  vessel  wall 
dilates. 

ANASTOMOSES. — The  anastomoses  take  place  by  convergence,  or 
by  longitudinal  communication  (Sappey).  Frequently,  the  anasto- 
motic  branches  are  much  finer  than  the  trunks  which  they  unite. 

SITUATION,  DIRECTION. — The  lymphatics  are  almost  exclusively 
situated  in  structures  of  the  connective  tissue-type,  for,  with  the 
exception  of  the  perivascular  sheaths  of  the  nervous  system,  whose 
functions  are  under  discussion,  they  never  encroach  upon  the 
epithelial  structures  or  their  derivatives  (Renaut).  According  to  their 
situation,  that  is,  above  or  below  the  fascia,  on  the  surface  of,  or 
within  the  viscera,  the  white  vessels  are  termed  either  superficial  or 
deep.  As  a  rule,  there  is  a  communication  between  the  superficial 
and  deep  visceral  lymphatics  ;  Mascagni  thought  that  the  same  held 
good  for  the  lymphatics  of  the  limbs  ;  Sappey,  on  the  contrary, 
upheld  the  absolute  independence  of  the  epi-and  subfascial  plexuses. 
According  to  Poirier.  it  can  only  be  a  question  of  relative 
independence,  for  such  communications  are  fairly  common,  especi- 
ally in  the  articular  regions. 

Rarely  sinuous,  the  lymphatics  are  almost  always  grouped  to- 
gether in  the  neighbourhood  of  blood-vessels,  which  they  accompany 
in  almost  a  straight  line.  Poirier  observed  that  lymphatic 
vessels,  which  p  ursue  a  straight  course  in  the  different  segments  of 
the  limbs  become  sinuous  in  the  articular  regions ;  similarly, 
in  the  case  of  the  visceral  lymphatics,  the  white  vessels  may  be 
seen  to  describe  many  curves,  varying  with  the  displacements  and 
changes  in  volume  of  the  organ  ;  thus  they  become  flexuous  at  the 
sides  of  the  uterus  and  in  the  neck  (Poirier),  and  under  the  frae- 
num  of  the  glans  (Marchand),  they  become  knotty,  etc.,  etc. 
Beaunis  and  Bouchard  reject  the  opinion  that  the  muco- 
cutaneous  lymphatic  networks  lie  above  the  blood-vessels ; 
they  state  that  the  lymphatic  vessels  are  always  and  everywhere 
more  deeply  situated  than  the  arteries  and  veins.  Ranvier  makes 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM  65 

the  same  statement,  and  remarks,  that  it  constitutes  a  law  the 
physiological  significance  of  which  we  can  understand,  seeing 
that  the  lymphatics  receive  material  which  the  blood  capillaries 
have  been  unwilling  or  unable  to  take.  Poirier  says  that  though 
this  is  true  for  the  networks  of  origin,  it  does  not  hold  good  for  the 
largest  vessels.  There,  on  the  contrary,  lymphatic  vessels  may  be 
seen  superposed  on  the  larger  veins,  which  they  accompany  for  choice ; 
in  the  popliteal  space,  in  the  inguinal  region,  in  the  iliac  fossa,  in 
the  axilla,  and  in  the  neck,  he  affirms  that  the  large  lymphatic  vessels 
and  the  glands  which  they  unite  in  a  chain,  are  placed  immediately 
over  the  large  veins  of  these  regions  ;  it  is  only  rarely  that  we  see 
some  of  the  trunks  pass  behind  the  veins.  We  know  of  hardly 
an  exception  to  this  law  established  by  our  master.  Surgeons,  who 
frequently  have  to  dissect  out  diseased  lymphatic  chains,  will  con- 
firm the  accuracy  of  this  statement.  Such  an  arrangement  is  for- 
tunate, as  it  makes  the  dissection  easier  than  it  otherwise  would  be, 

LYMPHATIC  TERRITORIES. — The  networks  of  origin,  of  a  given 
organ,  or  a  given  region,  often  give  rise  to  collecting-trunks, 
which  leave  the  network  at  different  points,  thus  constituting 
several  distinct  pedicles.  Granting  the  continuity  of  these 
trunks  with  the  networks  of  origin,  it  would  seem  at  first  sight, 
that  an  injection  made  at  any  point  into  the  latter  would  fill  the 
network,  and  then  penetrate  into  the  collecting  trunks  ;  and  as  a 
matter  of  fact,  in  certain  organs  where  the  network  presents  a 
particular  kind  of  development,  and  where  certain  conditions  pre- 
vail, which  favour  the  passage  of  the  mass,  this  total  injection 
can  be  obtained ;  but  it  is  no  less  true,  that  normally,  the  puncture 
of  a  given  point  of  the  network  injects  by  preference  certain  col- 
lecting-trunks-. We  are  led  to  believe  that  each  group  of 
pedicles  more  especially  drains  a  definite  portion  of  the  organ 
punctured.  It  is  therefore  reasonable  to  assume  that  in  this 
network,  notwithstanding  its  continuity,  there  are  really 
several  territories,  each  of  which  corresponds  to  a  given  group 
of  collecting- trunks.  It  is  certain,  however,  and  we  cannot  repeat 
it  too  often,  that  the  independence  of  these  territories  is  altogether 
relative,  since  we  can,  by  a  single  puncture,  and  under  favourable  cir- 
cumstances, inject  all  the  collecting- trunks  ;  similarly  their  limits 
are  somewhat  ill-defined. 

We  can,  however,  at  least  in  certain  organs,  define  their  respective 
limits  with  sufficient  accuracy.  We  can  gauge  their  extent  and 
thus  determine  the  principal  lymphatic  channel  of  a  given  organ. 


66  THE    LYMPHATICS 

Now  this  knowledge  is  of  considerable  practical  importance,  for 
neoplastic  formations  to  some  extent  exaggerate  this  arrangement. 
UNEQUAL  DISTRIBUTION. — The  lymphatics  are  unequally  dis- 
tributed throughout  the  organism  ;  and  we  are  almost  entirely 
ignorant  of  the  reason  of  this  apparently  capricious  distribution. 
Sappey  was  astonished  to  find  that  the  large  intestine  possessed  more 
white  vessels  than  the  small  intestine.  This  fact  well  shows  that 
the  richness  in  lymphatics  of  a  given  organ  is  not  directly  propor- 
tionate to  its  absorbent  functions  ;  for  the  bladder,  whose  healthy 
mucous  coat  is  impermeable,  possesses  lymphatics. 

The  number  of  lymphatics,  moreover,  apparently  bears  no  constant 
relation  to  the  elaboration  of  products,  secreted  and  excreted  by 
the  glands,  for  they  are  numerous  in  the  mamma  and  liver,  but 
more  scanty  in  the  kidney,  pancreas,  and  thyroid  body ;  on  the  other 
hand,  they  are  found  in  abundance  in  the  centre  of  the  diaphragm, 
It  seems  as  though  the  texture  of  the  surrounding  connective 
tissue  influences  their  number  as  well  as  their  shape.  If  the 
connective  tissue  is  lax,  their  habitual  tendency  to  run  together 
renders  them  sinuous  or  sacciform.  They  are  rarely  very  large. 
If  the  connective  tissue  is  sufficiently  dense  to  resist  their 
dilation  and  fusion,  they  become  numerous  but  smaller  in  size. 
Thus,  Regaud  observes  that,  in  the  same  organ  in  different 
species,  the  lymphatic  radicles  increase  or  diminish  in  pro- 
portion as  the  meshes  of  the  connective  tissue  are  dense  or 
lax;  in  other  words,  as  the  drainage  of  the  lymph  is  difficult 
or  easy. 

Now  do  lymphatics  exist  in  all  parts  of  the  organism  ?  Sappey, 
as  we  know,  denied  their  existence  in  the  connective  tissues,  in  bone, 
in  the  visceral  and  articular  serous  membranes,  in  the  arterial  walls, 
in  the  utero-vesical  mucous  membranes,  and  in  the  nervous  system. 
Though  it  has  been  satisfactorily  proved  that  the  connective  tissue 
is  almost  the  exclusive  seat  of  the  white  vessels,  their  presence  in  ten- 
dons and  aponeuroses,  which  was  demonstrated  by  Ludwig  and  Schwe- 
igger-Seidel  is  also  clearly  proved.  Budge,  following  Cruikshanks, 
Brugmanns,  and  Bonamy,  has  found  lymphatics  in  bone.  Tillmanns 
has  described  the  lymphatics  of  the  articular  serous  membranes  :  and 
we  cannot,  after  the  labours  of  Recklinghausen  and  Ranvier,  deny 
their  existence  in  the  visceral  and  serous  membranes.  The 
researches  of  Hoggan,  d'Albarran,  Pasteau,  and  Gerota  demon- 
strate the  existence  of  vesical  lymphatics ;  but  in  spite  of  the 
assertions  of  Hunter,  Cruikshanks,  Mascagni,  Lauth,  and  Breschet, 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM    67 


the  existence  of  arterial  lymphatics,  however  probable,  is  still 
a  moot  point. 

As  regards  the  nervous  system,  the  question  is  far  from  being 
definitely  solved.  In  fact,  ordinary  white  vessels,  perivascular 
sheaths,  neuroglia  spaces,  and  even  serous  clefts,  have  been 
described  as  lymph-channels.  Mascagni,  Fohmann,  Arnold,  and 
Breschet  figured  lymphatics  which  they  had  injected  on  the  sur- 
face of  the  brain.  Sappey  thought  this  was  a  matter  of  injections 
having  been  made  into  the  veins  or  into  the  cellular  tissue,  and  this 
opinion  has  been  generally  accepted.  Notwithstanding  this,  Poirier 
maintains  that  he  has  seen  indisputable  lymphatic  vessels  on  the  ex- 
ternal surface  of  the  brain  in  the  arachnoid,  and  in  the  dura  mater. 

As  regards  the  perivascular  spaces  of  Robin  and  His,  though  their 
existence  may  be  undeniable,  their  function  has  been  much  discussed. 
Their  lymphatic  nature,  which  was  at  first  almost  universally  ad- 
mitted, is  now  contested.  Renaut  does  not  admit  the  existence 
of  the  endothelium  formerly  described  by  His  and  Eberth  ;  in  his 
opinion  these  spaces  are  merely  emanations  from  the  amorphous 
part  of  the  membrana  propria  which  has  been  compressed  by  the 
blood-vessels. 

Though  the  spaces  studied  by  Obersteiner,  Friedmann,  Paladino, 
Klebs,  Rossbach,  Schrwald,  Kadyi,  d'Abundo  and  Guillain  physio- 
logically appear  to  have  the  significance  of  lymphatic  passages, 
their  morphology  does  not  permit  of  our  grouping  them  with  ordi- 
nary white  blood-vessels.  The  same  remark  holds  good  for  the 
canal  of  the  ependyma,  and  for  the  serous  cavities.  Later  on,  how- 
ever, we  shall  have  occasion  to  study  the  morphological  affinities 
of  the  serous  membranes  and  the  lymphatics. 

STRUCTURE. — According  to  their  structure,  lymphatic  vessels  be- 
long, some  to  the  type  of 


capillaries,  others  to  that 
of  the  collecting -trunks.  In 
the  capillaries,  the  lymph 
trickles  rather  than  circu- 
lates, but  even  in  the 
smallest  trunks,  the  circu- 
lation is  very  active.  If 
Prussian  blue  is  injected, 
it  quickly  disappears  (Ran- 
vier). 

The    capillaries    which 


FIG.  11. — Lymphatic  trunk  of  the  subserous  layer 
of  the  stomach  of  man  (removed  by  operation). 
The  lymphatic  endothelium  is  stained  with  silver 
nitrate. 


68 


THE    LYMPHATICS 


have  no  valves  are  reduced  to  an  endothelial  layer.  The  endothe- 
lium  of  the  collecting- trunks,  which  always  possess  valves,  is 
surrounded  by  an  elastic  and  muscular  sheath  of  connective  tissue. 
The  development  of  this  musculature  is  somewhat  variable  ; 
thus,  certain  trunks  which  run  in  the  subcutaneous  fibrocellular 
layer  (panniculus  acliposus)  have  no  muscle  (the  lymphatic 
venules  of  Renaut)  ;  again,  the  thoracic  duct  of  man,  which  is 
more  muscular  than  that  of  the  dog,  is  a  lymph  propeller  of  the 
same  type  as  the  smaller  trunks  for  which  Renaut  reserves  this 
term. 

Collecting-Trunks. — With  few  exceptions,  the  lymphatic  trunks, 
whatever    their    calibre,    have   the  same    fundamental   structure. 

For  the  sake  of  convenience,  we 
mav  regard  the  wall  of  the  thoracic 
duct  as  being  formed  of  three 
coats,  namely  an  internal  or  en- 
dothelial, a  middle  or  muscular, 
and  an  external  or  connective 
tissue  coat.  In  reality,  the  internal 
or  endothelial  coat  is  covered  by  a 
diffuse  connective  tissue  sheath  in 
which  the  elastic  and  muscular 
elements  are  irregularly  scattered. 
The  endothelial  cells  which 
were  discovered  before  those  of 
the  blood-vessels,  are  flat  and  elongated  in  the  long  axis  of  the  ves- 
sel ;  their  edges  are  straight  in  the  subclavian  region,  and  are 
wavy  lower  down.  This  is,  says  Ranvier,  the  elementary  form 
of  an  arrangement  which  is  very  well  marked  in  the  capillaries. 
It  is  nevertheless  to  be  borne  in  mind  that,  neither  in  the 
thoracic  duct,  nor  in  the  mesenteric  vessels  of  the  rabbit 
have  the  endothelial  cells  the  characteristic  resemblance  to  an 
oak  leaf.  The  endothelium  of  the  thoracic  duct  in  the  subclavian 
region  is  the  same  as  it  is  in  that  of  a  collateral  vein.  Renaut 
has  made  the  same  observation  in  the  horse  ;  this  fact  appears 
to  him  to  militate  in  favour  of  the  venous  origin,  and  centri- 
fugal development  of  the  thoracic  duct.  The  valves  are  simple 
folds  of  endothelium  ;  on  their  internal  surface,  the  cells  resemble 
those  which  line  the  vessel  wall ;  on  their  external  surface,  they 
are  polygonal  and  nearly  equal  in  all  their  dimensions. 

In  a  transverse  section,  the  cells  by  no  means  resemble    each 


FIG. 


J.Lcula. 

\'2. — A     transverse   section    of    the 
thoracic  duct  of  the  dog. 


GENERAL   ANATOMY  OF  THE  LYMPHATIC  SYSTEM    69 


other.  Some  have  a  moderate  amount  of  homogeneous  proto- 
plasm ;  and  an  oval  nucleus  with  one  or  two  granules  of 
chromatin ;  others  possess  a  fine  proto- 
plasmic border  from  which  escape  small 
spherical  granules  which  may  be  stained 
by  certain  colouring  acids  (eosin,  lichtgriin). 
The  nucleus  of  the  latter  cells  is  more 
elongated,  and  flatter  than  those  of  the 
former :  it  nearly  always  stains  diffusely 
and  deeply.  It  may  perhaps  be  that  these 
cells  destroy  themselves  during  the  pro- 
cess of  secretion  ;  in  fact,  the  works  of 
Heidenhain,  and  Hamburger  lead  us  to 
think  that  the  lymphatic  endothelium,  far 
from  being  a  simple  membrane  endowed 
with  physical  properties,  takes  an  active 
part  in  the  elaboration  of  the  lymph. 
Further,  Ranvier  has  demonstrated  the  his- 
tological  reality  of  this  secretory  function 
of  the  lymphatic  endothelium,  and  has  stated 
that  the  cells  of  the  lymphatic  vessels  of 
the  rabbit's  ear,  in  the  normal  state,  elabor- 
ate a  hyaline  substance,  quite  different  from 

eleidin.  This  substance  swells  up  as  myelin  does  ;  it  is  cast  off 
from  the  endothelium  in  the  shape  of  balls,  which  when  small 
appear  homogeneous ;  but  which,  when  larger,  exhibit  a  clear  centre 
and  a  refracting  envelope.  They  finally  fuse  with  each  other  and 
the  figure  formed  resembles  a  network,  with  fibrillary  arches. 
Picrocarmin  does  not  stain  them,  or  stains  them  only  pale  yellow, 
though  it  stains  eleidin  a  vivid  red. 

The  connective  tissue  envelope  is  composed  of  lax  tissue  and  of 
fairly  strong  longitudinal  fibres.  In  the  dog  and  ass,  Renaut  has 
seen  the  connective  tissue  cells,  which  were  negatively  stained  by 
silver  nitrate,  shew  beneath  the  endothelium,  beautiful  Langhans' 
bodies  crossing  each  other  in  every  direction.  This  sub-endothelial 
connective  tissue  layer  is  very  scanty  in  the  dog  and  in  man. 
Externally,  the  connective  tissue  layer  insensibly  merges  into 
that  of  the  mediastinal  cellulo-adipose  tissue.  Frequently,  the 
lymphatic  wall  is  penetrated  by  some  fatty  cells.  This  continuity 
with  the  surrounding  tissue  is  one  of  the  fundamental  character- 
istics of  the  structure  of  white  vessels.  In  the  dog,  some  cells  of 

F 


FIG.  13. — Transverse  section 
of  the  thoracic  duct  of  the 
dog.  The  adventitia  is 
continuous  with  the  sur- 
rounding celluio  -  adipose 
tissue  ;  in  the  middle  por- 
tion sections  of  two  blood 
vessels  are  seen. 


70 


THE    LYMPHATICS 


vein — i 


Ehrlich  are  found,  around  and   even  in  the  wall  of  the  thoracic 

duct.     In  the  small  trunks,   the  tissue  is  lax  and  does  not  contain 

longitudinal  fibres  (Renaut). 

By  the  side  of  the  connective  tissue  fibres,  are  found  very  fine 

elastic  fibres  which  constitute  a  delicate  sub-endothelial  network. 

In  this  elastic  con- 
nective tissue  layer, 
and  especially  in  its 
middle  portion,  are 
scattered  fine  mus- 
iK'SS  cular  fibres.  In  the 

dog,  they  are,  for  the 
greater  part,  trans- 
verse ;  but  some  are 

...lymphatic  obli<lue-  In  man, they 
are  longitudinal,  ob- 
lique and  transverse  ; 

FJG.    14. — Transverse     section    of    vessels    and    nerves    in    a     the  latter  always  pre- 
doe's  mesentery.     Notice  the  thickness  and  relative  dimen-       -,         •        ,.  T       .,  . 

sions  of  the  artery,  vein,  and  lymphatic.  dominating.       In  tlllS 

case,    doubtless      on 

account  of  the  vertical  position,  the  muscular  coat  is  more  de- 
veloped ;  this  forces  the  lymph  onwards  and  enables  it  to  overcome 
the  action  of  gravity  (Ranvier). 

It  is  in  the  region  of  the  lymphatic  enlargements  above  the  valves 
(which  are  numerous  in  the  small  collecting  trunks)  that  the 
oblique  fibres  predominate.  The  fibres  here  intertwine  in  all 
directions  and  form  rich  plexuses.  In  this  respect,  these  supra- 
valvular  enlargements,  which  are  really  true  contractile  sacs,  remind 
us  of  the  lymphatic  hearts  of  batrachians. 

The  presence  of  the 
three  elements,  viz.  the 
elastic,  the  connective 
tissue  and  the  muscular, 
explains  the  physical  pro- 
perties of  the  lymphatic 
wall  which,  in  spite  of  its 
fineness  is  resistant,  exten- 
sible, and  retractile.  Its 
resistance  is  fairly  great, 
seeing  that  it  can  sup- 

FIG.  15. — Nerves  of  the  thoracic  duct  (stained  with  the 
methylene  blue  method).     After  Kytmanoff. 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM  71 

pressure  of  a  column  of  mercury  of  from  30  to  40  centimetres, 
and  sometimes  even  that  of  from  60  to  80  centimetres  (Sappey). 
When  injected,  the  lymphatic  vessels  dilate  more  than  the  arteries 
and  less  than  the  veins  (Sappey). 

The  walls  of  the  lymphatic  trunks  are  rich  in  vessels  and  in  nerves  : 
each  pulmonary  lymphatic,  for  example,  is  interwoven  with  a 
network  of  blood-vessels  with  large  longitudinal  meshes  (Sappey). 

De  Timofejew  and  Dogiel  have  seen  nerve  filaments  surrounding 
the  lymphatics  of  the  cord,  the  prepuce,  and  the  gall-bladder. 
Smirnow  has  found  sensory  and  motor  nerve-endings  in  the  lymphatics 
of  the  cord.  In  the  thoracic  duct  of  the  dog,  Quenu  and  Darier 
have  seen  fibres,  entirely  destitute  of  myelin,  form  an  adventitious 
plexus,  without  any  ganglion  cells.  From  his  researches,  carried 
out  according  to  Ehrlich's  method,  Kytmanoff  concludes  that 
the  nerves  of  lymphatics,  which  are  chiefly  formed  by  the  fibres  of 
Remak,  also  contain  some  fibres  with  myelin.  He  describes 
adventitious,  supramuscular  and  sub-endothelial  plexuses.  The  fine 
varicose  fibres  of  the  latter  plexus  resemble  those  of  arterial 
vessels.  There  are  motor  terminations  in  the  muscular  fibres. 
The  terminations  of  the  sensory  nerves  of  the  external  and 
middle  coats  are  sometimes  free,  at  others,  end  in  small  bunches,  or 
in  figures  resembling  a  bush  or  small  tree. 

In  the  arrangement  of  their  muscular  fibres  in  rings,  and  in 
their  sub-endothelial  nerves  (Kytmanoff),  the  lymphatic  trunks 
resemble  arteries  ;  in  the  fineness  of  their  wall,  in  their  endothelium 
(Ranvier),  and  in  the  presence  of  valves  they  are  much  more 
similar  to  veins. 

Capillaries. — The  walls  of  lymphatic  capillaries  simply  consist  of  a 
stratum  of  endothelial  cells  applied  directly  to  a  connective  tissue 
framework.  The  form  and  calibre  of  these  vessels  is  determined 
by  the  texture  of  the  connective  tissue  in  which  they  lie ;  an 
explanation  which  accounts  for  their  polymorphism.  Frequently, 
neighbouring  connective  tissue-bundles  which  are  close  to  each  other, 
entirely  deprive  a  pliable  membrane  of  its  lymphatic,  and  cause 
its  lumen  to  disappear  entirely.  The  vessel  then  only  manifests  its 
presence  by  a  collection  of  nuclei  analogous  to  those  of  flat  cells,  which 
are  found  elsewhere  between  bundles  of  connective  tissue.  It  is  im- 
possible to  recognize  it.  The  same  difficulty  presents  itself  when 
there  are  only  one  or  two  parietal  nuclei  visible  in  the  section. 
Klein  and  Burdon  Sanderson  have  remarked  that,  in  sections,  the 
endothelial  cells  were  more  prominent  and  more  turbid  than  those  of 


72  THE    LYMPHATICS 

blood-vessels.  Their  nuclei  project  into  the  vascular  cavity, 
which  appears,  says  Renaut,  as  though  lined  by  a  row  of 
little  pearls.  This  projection  varies  :  thus  if  the  vessel  is  distended, 
it  is  hardly  apparent ;  if  the  vessel  is  not  distended,  it  becomes  more 
marked.  This  nucleus,  which  is  almost  oval,  frequently  presents  a 
marginal  notch  ;  it  is  dotted  with  very  fine  chromatin  granules 
which  are  sometimes  scattered  throughout  its  extent,  sometimes 
arranged  in  linear  and  parallel  series,  and  sometimes  again 
they  are  grouped  together  at  the  periphery. 

It  is  not  uncommon  to  find  some  of  these  cells  in  process 
of  degeneration  :  their  protoplasm  becomes  vacuolated  and  their 
nucleus  shrivels  up  or  the  chromatin  granules  run  together.  We 
may  sometimes  see  the  endothelial  cells  of  the  capillary  lymphatics 
of  the  gland  expel,  not  only  chromatin  particles,  but  also  small 
albuminoid  spherules,  which  have  been  stained  by  certain  colour- 
ing acids  (lichtgriin,  eosin). 

The  lymphatic  capillaries  are  more  easily  stained  by  silver 
nitrate  than  are  the  blood  capillaries  (Ranvier)  :  thus  stained,  the 
endothelial  cells  which  measure  from  30  to  40  ya  in  their  long  axis, 
appear  marked  out  by  black  lines,  which,  like  the  sutures  in  the  bones 
of  the  cranial  vault,  are  sinuous  (Mathias  Duval).  It  is  usual  to 
compare  the  borders  of  these  cells  to  an  oak-leaf  or  the  dovetailed 
edge  of  a  child's  puzzle. 

Here  and  there,  little  protoplasmic  areas  are  found  which  have 
no  nuclei  and  which  have  been  described  by  Auerbach  as  "  Schalt- 
platten.'r  According  to  Renaut,  these  intercalary  surfaces  show  that 
at  a  certain  period  of  its  development,  the  lymphatic  capillary 
must  have  been  formed  from  an  undivided  protoplasmic  lamina 
interspersed  with  nuclei. 

The  diameter  of  the  lymphatic  capillaries  varies  between  30  and 
60  /x  ;  it  is  therefore  much  larger  than  that  of  the  blood  capillaries 
which  may  be  only  7  p  (Mathias  Duval). 

There  is  another  difference  between  the  blood-capillaries  and  the 
lymphatics.  If  we  remove  the  capillaries  from  a  lymphatic  gland, 
we  see  that  the  white  vessels,  instead  of  being  placed  between  those 
of  ingress  and  egress,  as  is  the  case  with  the  capillary  blood-vessels, 
are  placed  at  the  peripheral  end,  at  the  very  commencement,  in 
fact,  of  the  lymphatic  system. 

Origin  of  the  Lymphatics. — The  controversies  and  theories  which 
have  arisen  as  to  the  origin  of  lymphatics  are  well  known.  The 
larger  number  of  theories,  founded  on  errors  of  observation  or  upon 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM     73 


hypotheses  which  have  since  been  invalidated,  are  only  interesting 

as  an  historical  curiosity.  It 
is  now  quite  certain  that  the 
"  capillicules  "  of  Bartholin, 
Arnold  and  Sappey,  which  are 
placed  between  the  arteries 
and  lymphatics,  have  no  more 


«r&vP".f,f*»" 


FIG.  16. — Origin  oi  lymphatic  vessels  in  a  papilla  of  the  hand  (after  Sappey). 
A .  Lymphatic  vessels  of  a  papilla  of  the  palm  of  the  hand. 

1,1,1,1.  Two  lymphatic  branchlets,  composed  of  five  lacunae  which  are  continuous 
with  each  other.  They  occupy  the  summit  of  the  papilla  and  in  uniting  give  rise  to  the 
central  trunk. — 2.  A  curved  lymphatic  branchlet  which  opens  into  the  highest  part  of 
this  trunk. — 3.  Two  other  longer  lymphatic  branchlets  which  unite  to  form  a  network, 
which  almost  immediately  joins  the  central  trunk  of  the  papilla. — 4.  A  little  branch  opening  by 
its  two  extremities  into  this  trunk,  and  communicating  in  its  course  with  the  lacunae  and  small 
capillaries  which  surround  it. — 5,5,5.  Three  little  branches  which  extend  like  so  many  longi- 
tudinal anastomoses  from  a  point  on  this  trunk  to  a  part  lower  down. — 6,6.  Central  trunk. 
— 7,7,7,7.  Lacunae  which  are  continuous  with  the  surrounding  capillaries. — 8,8.  Capillaries 
which  are  continuous  with  eacli  other  and  with  neighbouring  lacunae. 

B.    Lymphatic  vessels  from  a  papilla  of  the  eyelid. 

1,  1,  1,  1,  1.  Isolated  lacunae. — 2,2,2.  Capillaries.  —  3,3,3,3.  Lacunae  continuous  with  each 
other  and  forming  little  branches. — 4.  Trunk  into  which  these  little  branches  eventually  open. 

existence  than  have  the  "  juice  canals "  of  Recklinghausen  or 
the  "  serous  vessels "  of  Boerhave.  Contrary  to  the  opinion 
originally  held  by  Mascagni  and  Bichat,  and  at  first  adopted  by 
Ranvier,  it  appears  almost  certain  that  the  lymphatics  have  no 
openings  in  the  meshes  of  the  connective  tissue.  If  such  communi- 
cations existed,  the  injection  of  capillary  lymphatics  would  certainly 
be  followed  by  extravasations  ;  but  this  is  not  the  case  (Arloing). 
It  is  quite  probable  that  interstitial  injections  penetrate  into  the 
lymphatics,  because  the  point  of  the  needle  tears  their  frail 
endothelium. 

In  a  word,  no  one  has  ever  seen  these  alleged  orifices,  and  nearly 
all  contemporary  histologists  are  unanimous  in  stating  that  in  the 


THE    LYMPHATICS 


adult,  as  in  the  foetus,  the  lymphatic  capillaries  terminate  by  abso- 
lutely closed  cuts  de  sac. 

The  shape  of    these    culs    de    sac  varies  :    they  are    sometimes 

ampullary, 
sometimes  club- 
shaped,  and 
may  or  may 
not,  shew  later- 
al bosses  ;  they 
may  be  coni- 
cal, digitiform 
or  even  pointed, 
and  sometimes 
again,  they  may 
resemble  a  key 
ring.  On  the 
other  hand,  in 
spite  of  the  pre- 
sence of  a  con- 
tinuous endo- 
thelium,  the  re- 
lations between 

vascular  cavity  and  the  connective  tissue-spaces  !  remain 
close.  Cellular  migrations  and  osmotic  exchanges  can 
always  take  place,  and  the  capillaries  fulfil  their  function  of  drains, 
and  perhaps  if  the  observations  of  Renaut  are  confirmed, 
may  even  act  as  selective  drains.  In  fact,  as  a  result  of  his  researches 
into  the  lymphatic  capillaries  of  the  lax  connective  tissue  of  the 
marmot,  Renaut  thinks  he  may  legitimately  conclude  that  these 
vessels  contain  neither  white  corpuscles  nor  albuminous  plasma  : 
and  that  the  liquid  they  do  contain,  apparently  consists  solely 
of  water,  and  crystalloids,  which  are  unstained  by  osmic  acid,  and 
that  it  is  only  the  lymphatics  which  possess  valves  which  contain 
leucocytes  and  albuminoids.  Now,  do  not  the  lymphatic  capillaries 
communicate  more  constantly  and  directly  with  the  serous  mem- 
branes or  with  veins  than  with  the  connective  tissue  ?  A  priori, 
our  knowledge  of  the  permeability  of  the  lymphatic  endothelium 
enables  us  to  understand  that  it  may  be  traversed  by  substances 
coming  from  the  peritoneum  or  the  blood,  although  it  shows  no 
open  orifice.  The  experiments  of  Recklinghausen,  Ludwig  and 
Schweigger-Seidel  do  not  necessarily  imply  the  existence  of  channels 


Fio.  17. — Lymphatic  network  of  the  submucous  gastric  layer 
of  the  rabbit :  closed  ampullae  ;  small  calibre  of  the  anasto- 
motic  branches  ;  dilatation  of  the  confluents.  (Intra-va ;cular 
injection  of  silver  nitrate.) 


the 


verv 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM     75 

or  orifices  between  the  peritoneum  and  the  lymphatics.  In  the 
same  way,  the  possibility  of  injecting  the  lymphatics  by  the  arteries, 
the  presence  of  red  blood  corpuscles  in  the  lymph,  may  be  explained 
otherwise  than  by  the  presence  of  any  kind  of  peripheral  con- 
tinuity between  the  two  systems  of  vessels. 

These  theoretical  inductions  are  confirmed  by  the  data  of 
direct  observation  which  show,  in  the  first  place,  that  the  lymphatic 
openings  in  the  diaphragm  are  far  from  representing  permanently 
open  channels  of  communication,  between  the  serous  membranes  and 
the  vessels,  and  secondly,  that  the  arterio-lymphatics  do  not 
exist. 

To  sum  up.  The  lymphatic  capillaries  are  invariably  absolutely 
closed,  and  communicate  neither  with  the  connective  tissue,  nor 
with  the  serous  membranes,  nor  with  the  blood-vessels.  They  are, 
however,  none  the  less  in  very  intimate  physiological  relation  to 
these  various  structures,  a  relation  which  has  been  demonstrated 
by  both  normal  and  pathological  physiology. 

Development. — The  embryonic  lymphatic  vessels  cannot  be 
stained  with  silver  nitrate.  To  show  them,  we  must  use  either  an 
interstitial  injection  of  a  staining  material,  or  osmic  acid,  which 
stains  their  outlines  brown.  The  many  technical  difficulties  pre- 
sented by  their  study  explain  the  scarcity  of  works  on  this  subject 

Koelliker  thought  he  saw  in  the  tadpole's  tail  the  lateral  points 
of  the  embryonic  lymphatics  continuous  with  the  connective  tissue- 
cells.  This  old  observation  may  be  disregarded,  says  Ranvier. 

Breschet  made  a  more  correct  statement  when  he  said  that  the 
lymphatic  vessels  always  developed  before  the  glands.  This  remark, 
which  has  since  been  verified  by  Ranvier,  is  interesting,  for,  in  the 
animal  series,  the  lymphatic  vessels  appear  before  the  glands  have 
any  existence.  Ranvier  has  stated  that  in  pig-embryos  which 
measure  less  than  9  centimetres  from  the  sinciput  to  the  commence- 
ment of  the  tail,  the  lymphatics  are  absent,  but  that  in  those 
measuring  10  centimetres,  the  thoracic  duct  is  present,  and  the 
valves  are  perfectly  efficient. 

From  the  first,  the  trunks  are  distinguishable  from  the  capillaries  J 
the  former  very  soon  show  their  valves  and  develop  from  buds 
which  are  originally  full  ;  the  latter  spring  from  buds  originally 
hollow  and  which  have  no  valves. 

The  cells  of  the  full  buds  soon  secrete  a  liquid,  the  accumulation  of 
which  distends  the  vascular  cavity  and  thrusts  back  the  endothelium 
of  the  neck  ;  this  folded  back  endothelium,  a  true  collar,  represents 


THE    LYMPHATICS 


the  primitive  valve.     The  muscular  connective  tissue  layer  does  not 
appear  till  later. 

The  initial  lymphatic  growth,  which  is  at  first  very  active,  is 
sometimes  followed  by  involution  phenomena,  which  have  been 
studied  by  Ranvier  in  the  epiploon  of  the  new-born  cat.  There, 
lymphatics  are  found  in  which  the  terminal  culs  de  sac  are 
twisted  into  the  shape  of  a  glomerulus  like  that  of  the  sweat  glands. 
In  some  cases,  the  lymph  is  retained  by  a  pair  of  valves  whose 
action  is  reversed  ;  in  others,  closed,  elongated,  or  actually  pointed 
vesicles  are  seen,  which  represent  portions  of  the  lymphatic 
system  wrhich  have  become  isolated  in  consequence  of  the  atrophy 
of  intermediate  segments.  Again,  in  the  pig,  vesicles  may  be  found 
which  are  at  times  bound  by  a  caniliculus  to  a  completely  closed 
valvular  segment,  and  which  at  others,  are  isolated.  They  may  be 
the  origin  of  certain  cystic  formations. 

Ranvier  maintained  also  that  wherever  lymphatics  are  in  contact 
with  each  other  in  a  lax  tissue,  they  tend  to  run  together  and  to 

become  sacciform.  He  compares 
the  development  of  lymphatics 
with  that  of  the  glands :  the 
lymphatic  system  is,  in  his  opin- 
ion, an  immense  gland  which 
originates  from  the  veins,  into 
which  it  throws  the  product  of 
its  secretion — the  lymph. 

Sala  has  traced  the  formation 


Fio.  18.— Lymphatics  in  involution  :  a  lymphatic    vesicle    in   continuity   with    the  neigh- 
bouring  trunk  ;  isolated  vesicle  (after  Ranvier). 

of   the   thoracic   duct   in   the    chicken.      The    first    indication    of 
it    appears    a    little    later    than    that    of    the   lymphatic    hearts, 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM     77 

viz.  in  the  second  half  of  the  eighth  day.  At  this  period, 
in  the  region  extending  from  the  commencement  of  the  brachio- 
cephalic  trunk  to  the  junction  of  the  ductus  arteriosus  and 
aorta,  are  found  groups  of  rounded  mesenchymatous  cells,  with  large 
nuclei  rich  in  chromatin.  These  elements  constitute  a  dense  cord, 
which,  on  becoming  hollowed  out,  shows  the  rudiments  of  the 
thoracic  duct.  It  becomes  hollowed  out  more  quickly  in  the 
thoracic  than  in  the  cervical  portion.  Communication  with  the  veins 
only  takes  place  later  on.  Injection  of  the  thoracic  duct  by 
puncture  of  the  lymphatic  heart  is  not  possible  before  the  twelfth 
day. 

This  author  is  of  opinion  that  the  lymphatic  hearts  appear,  as 
irregular  fissures  of  the  mesenchyme,  at  the  eighteenth  hour  of  the 
sixth  day.  The  wall  is  entirely  formed  of  elongated  mesenchymatous 
cells  ;  the  more  internal  are  flattened  so  as  to  constitute  the 
endothelium.  All  the  lymphatic  spaces  appear  as  chinks  in  the 
mesenchyme  in  the  latter  hours  of  the  ninth  day.  The  researches  of 
Sala  confirm  those  of  Bonnet,  Gulland  and  Saxer  ;  they  clearly  show 
that  the  lymphatic  vessels  are  formed  in  the  meshes  of  the  connective 
tissue,  in  the  extra-cellular  spaces.  This  is  contrary  to  the  opinion 
of  Klein  (1873)  and  Retterer  (1902),  who  maintain  that  the  lumen  of 
lymphatic  radicles  is  formed  in  the  mesenchymatous  cells  themselves. 

A  Review  of  the  Lymphatic  Vessels  in  the  Animal  Series. — The  lymphatic 
vessels  do  not  appear  until  a  somewhat  late  period  of  ontogenesis,  much 
later  than  the  arteries  and  veins.  The  same  remark  applies  to  their  phylo- 
genesis, where  they  do  not,  except  in  the  Teleosteans,  appear  with  any 
certainty.  Carl  Vogt  and  Yung  describe  the  lymphatic  system  of  the  perch 
as  formed  of  two  longitudinal  canals  situated  snbcutaneously  in  the  middle 
of  the  flanks  and  ending  in  a  pocket  placed  in  the  neighbourhood  of  the  last 
vertebra.  In  front,  these  canals  communicate  by  means  of  several  anasto- 
moses with  the  venous  system. 

The  lymphatics  are  more  developed  in  the  tailless  Batrachians.  From 
the  commencement  there  are  capillaries  in  the  interdigital  membrane, 
absolutely  similar  to  those  found  in  mammals.  These  capillaries  end  in 
enormous  sacs,  which  were  formerly  regarded  as  serous  or  connective  tissue- 
spaces:  in  reality  they  are  lymphatic  capillaries  which,  having  united 
together,  have  become  sacciform  and  attained  these  unusual  proportions. 
From  these  cutaneous  sacs,  the  lymph  passes  to  the  hearts,  which  throw  it 
into  the  venous  system. 

The  frog  possesses  four  lymphatic  hearts,  one  at  the  base  of  each  limb. 
The  anterior  hearts  are  situated  under  the  scapula,  and  communicate 
with  the  subscapular  vein.  The  posterior,  the  size  of  a  pin's  head,  lie  under 
the  skin  on  either  side  of  the  coccyx. 

They  are  formed  of  an  endothelium  which  is  lined  externally  with  a  layer 
of  striated  muscular  fibres,  the  thick  strands  of  which  form  the  boundaries 
of  somewhat  shallow  areolae. 


78  THE    LYMPHATICS 

At  the  venous  orifice,  there  are  placed  two  semiluiiar  valves,  which  prevent 
the  regurgitation  of  the  lymph.  In  frog's  hearts  are  found  a  large  number 
of  striated  muscular  bundles,  which  do  not  contain  nuclei,  but  which  possess 
multinuclear  protoplasmic  masses  on  their  surfaces.  These  bundles  are  of 
variable  sizes,  and  divide  or  anastomose  just  like  the  fibres  of  the  blood- 
heart  ;  these  cells  are  not  united  end  to  end  (Ranvier).  The  hearts  possess 
a  rich  network  of  blood  capillaries,  with  rounded  irregular  meshes,  very 
different  to  those  observed  in  ordinary  muscle. 

There  are  no  nerve-cells  ;  there  are,  on  the  contrary,  many  nerves  with 
myelin,  which  terminate  as  in  voluntary  muscle,  in  bulbs  and  numerous 
arborizations  (Ranvier). 

In  reptiles,  there  are  two  lymphatic  hearts  on  each  side  of  the  body  above 
the  cloaca.  They  retrogress  in  birds  (Gadow).  According  to  Budge,  they 
are  present  in  the  embryo  of  the  chick,  but  disappear  with  the  development 
of  the  allantois.  Sala  found  traces  of  them  in  the  chick  thirty-five  days  old. 
In  mammals  they  seem  to  disappear  entirely,  but  in  reality  they  are  still 
represented  here  by  the  swellings  above  the  valves. 

i  In  the  mesentery  of  the  frog,  the  lymphatic  capillaries  form  true  serous 
peri  vascular  sheaths.  Similar  sheaths  are  found  round  the  pulmonary  artery 
of  the  ox  (Renaut).  Moreover,  it  is  the  perifollicular  sheaths  which  in  all 
mammals,  exhibit  the  old  tendency  possessed  by  the  white  capillaries  of 
grouping  themselves  round  organs  after  the  manner  of  serous  membranes. 
This  last  property  completes  the  series  of  characteristics  which  are  common 
to  the  two  classes.  We  have  already  remarked  that  in  becoming  confluent 
the  lymphatics  form  vast  endothelial  pockets  very  similar  to  the  large  serous 
cavities.  Budge  and  Sala  have  shown  that  the  lymphatic  spaces  are  formed 
from  simple  mesenchymatous  fissures.  Finally,  from  Sala's  researches  it  follows 
that  there  is  no  fundamental  difference  between  the  vascular  and  serous 
endothelia.  Embryology  and  comparative  anatomy  prove  that  the  muscular 
structures  are  secondary  and  superadded. 

There  is  then  a  striking  resemblance  between  the  white's  capillaries  and 
the  visceral  serous  membranes  ;  is  this  morphological  resemblance  a  real 
identity  ?  It  was  long  believed  to  be  so,  as  long,  in  fact,  as  investi- 
gators, impressed  by  the  well  known  experiments  of  Recklinghausen, 
believed  in  the  permanence  of  lymphatico-peritoneal  communications.  Since 
that  time,  however,  the  majority  of  authors,  struck  by  the  want  of  systematic 
arrangement  of  these  communications,  have  endeavoured  to  discover 
distinctive  characters  between  the  capillaries  and  the  serous  membranes. 
Some,  after  making  a  special  study  of  the  walls,  point  out  certain  structural 
differences  between  the  two  endothelia,  the  common  origin  of  which  is  known  ; 
others,  after  studying  the  contents,  declare  that  the  histochemical  compo- 
sition of  the  serous  cavity  is  not  identical  with  that  of  lymph.  This  is 
true,  but,  as  a  matter  of  fact,  there  is  less  chemical  difference  between  the 
composition  of  the  serous  contents  and  the  peripheral  lymph,  than  between 
the  latter  and  the  chyle.  It  is  therefore  not  justifiable  to  write  that 
"the  homology  between  the  serous  membranes  and  capillaries  cannot  be 
upheld,  except  by  admitting  that  the  lymph  varies  in  constitution 
according  to  the  parts  at  which  it  is  studied.  Such  an  hypothesis  has  not 
yet  been  established  by  experiment."  (Vide  this  Treatise,  vol.  iv.,page  1080.) 

To  sum  up.  From  the  above-mentioned  facts  it  follows  that,  the  system 
of  lymphatic  vessels  is  fundamentally  identical  in  Batrachians  and  in 
mammals.  All  the  structures  found  in  the  former  are  found  at  any  rate 
in  the  vestigial  state  in  the  latter.  The  only  important  differences  are  the 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM    79 

following  :  the  lymphatics  in  the  Batrachiaiis  and  in  the  Amphibians  empty 
themselves  into  the  venous  system  without  passing  through  intermediate 
glands.  It  is  known  that  glands  are  only  present  in  birds,  and  then 
apparently,  only  in  the  cervical  region.  Mascagni's  law  therefore  merely 
holds  good  for  the  lymphatics  of  mammals.  Finally,  in  the  Batrachians 
and  even  in  the  embryo  bird,  the  points  at  which  the  lymphatics  end  iri  the 
veins  are  multiple  :  the  two  systems  communicate  in  the  region  of  each  of 
the  four  lymphatic  hearts. 

BIBLIOGRAPHY. — Aristote.  Hist.  Anim.,  lib.  Ill  ; — Phys.,  I,  sect.  III. — 
Galien.  An  sanguis  nat.  in  arteris  contineatur,  cap.  5,  ad.  de  Admin.  Anat., 
lib.  VII  ; — De  usu  partium,  lib.  IV,  c.  19. — Nicolas  Massa.  Lib.  Introd.  Anat., 
1532. — Fallope.  Tractatus  quinque  de  partibus  similaribus. — Hewson.  An 
account  of  the  lymphatic  system  in  birds.  Phil.  Trans.,  I.VIII,  1708  ; — 
Experimental  inquiries  on  the  blood,  with  some  remarks  on  it  and  an  appendix 
relating  to  the  lymphatic  system  in  birds,  fishes  and  amphibious  animals. 
London,  1771. — Monro.  State  of  facts  concerning  the  paracentesis  of  the  thorax, 
on  account  of  air  diffused  and  lymphatic  vessels  in  oviparous  animals.  Bdim- 
bourg,  1770. — Mascagni.  Vasorum  lymphaticorum  corporis  humani  historia 
ct  iconocjraphia.  Sienne,  1787. — Bichat.  Traite  des  membranes,  1816. — 
Fohmann.  Anat.  Untersuch.  uber  die  Verbindung  der  Saugadern  mit  den 
Venen.  Heidelberg,  Neue  Akad.  Buchhand.  v.  Karl  Groos,  1821. — Lauth. 
Essai  sur  les  vaisseaux  lymphatiques.  These  Strasbourg,  1824. — Lippi. 
Illustrazioni  fisiologiche  e  patologiche  del  sistema  linfatico  chilifero,  mediante 
la  scoperta  di  un  gran  iiumero  di  comunicazioni  di  esso  col  venoso.  Firenze, 
1824. — Fohmann.  Memoires  sur  les  communicat.  der  vaiss.  lymphatiques 
avec  les  veines.  Liege,  1832. — J.  Muller.  Annales  de  Poggendorff,  1832. — 
Philos.  Trans.,  1833. — Panizza.  Sopra  il  sistema  linfaticho  dei  rettili,  Pavia, 
1833. — Stannius.  Ueber  die  Lymphherzen  der  Vogel.  Muller' s  Archiv, 
1842. — Rusconi.  Reflessioni  sopra  il  sistemo  linfatico  dei  rettili,  etc.  Pavia, 
1845. — Brucke,  Ueber  die  Chylusgefdsse  n.  die  Resorption  des  Chylus.  Wiener. — 
Kcelliker.  Note  sur  le  developpement  des  tissus  chez  les  batraciens.  Annales 
des  Sciences  Nat.,  1846,  IV  ; — Elements  d'histologie  humaine,  2  ed.  ; — Denk- 
schriften,  1854,  VI. — Leydig.  Histologie,  1857. — Milne-Edwards.  Physiologic 
ct  Anatomic  comparee,  1859,  IV. — Virchow.  Path,  cell.,  1861  ; — Rekling- 
hausen.  U.  die  Lymphgefasse  u.  Hire  Beziehung  zum  Bindegewebe.  Berlin, 
1862  ; — Zur  Geschichte  der  Versilberungsmethode.  Virchoiv's  Archiv,  1863, 
XXVIII,  p.  1119; — Strieker's  Handbuch,  1872. — Ch.  Robin.  Cours  d'his- 
tologie,  1864; — Article  "  Lymphatique  "  du  Diet.  DecJiambre. — Auerbach. 
Untersuch.  uber  Lymph,  u.  Blutgefasse.  Virchow' s  Archiv,  1865,  XXXIII. — 
Ludwig.  u.  Schweigger-Seidel.  Arbeiten  aus  der  physiologischen  Anstalt  zu 
Leipzig,  1867. — Tourneux.  Recherches  sur  repithelium  cles  sereuses.  Journ.  de 
VAnat.,  1874. — Klein.  The  anatomy  of  the  lympliatic  system  :  The  serous 
membranes.  London,  1873. — Rouget.  Arch.  Physiologic,  1873. — J.  Arnold. 
U.die  Beziehung  der  Blut ; — U.  Lymphgefasse  zu  den  Saftkanalchen.  Virchow' s 
Archiv,  1874. — Sappey.  Traite  d' anatomic,  physiologic  et  pathologic  des  vaisseaux 
lymphatiques,  1874  ; — Traite  tfanat.  descript.,  II. — Alferow.  Arch.  Physiol., 
1874. — Tarchanoff.  Des  pretendus  canaux  qui  feraient  communiquer  les 
vaisseaux  sanguins  et  lymphatiques.  Arch,  de  physiologic,  1875. — Tourneux 
et  Hermann.  Recherches  sur  quelques  epitheliums  plats  dans  la  serie  animale. 
Journ.  de  VAnat.,  1876.— Altmann.  Arch.  f.  mikr.  Anal.,  1879,  p.  471.— 
Thanhofer.  Das  Mikroskop,  1880. — Pierret  et  Renaut.  Memoires  sur  les 
sacs  lymphatiques  peril obulaires  du  poumon  de  bceuf.  Arch.  Phys.,  1881. — 
Budge  U.  das  dem  zweiten  Blntkreislauf  entsprechende  Lymphgefasssystem 


80  THE    LYMPHATICS 

bei  Huhnerembryonen.  Centralbl.  Med.  Wiss.,  1881,  n°  34  ; — Untersuch. 
tiber  die  Entwickelung  des  Lymphsystems  Hiihner  embryo.  Arch.  anat. 
Phys.  :  Anat.  Abth.,  1887. — Weliki.  Einige  Ergrdnzungen  zur  Histologie, 
Anat.  u.  Phys.  der  Lymphgefdsse,  1884. — Gierke.  Zeit.  f.  wiss.  Mikr.,  1884. — 
Hoggan.  Journ.  of  Anat.  and  Phys.,  1885,  XV. — Retterer.  Disposition  et 
connexions  du  reseau  lymphatique  dans  les  amygdales.  C.  R.  Soc.  Biol., 
23  Janvier  1886. — Dekhuysen.  Anat.  Anzeiger,  1889,  IV  ; — Zeit.  /.  miss.  Mikr., 
1890,  VII,  3.— Mayer.  Zeit.  f.  wiss.  Mik.,  1889,  VI,  4,  p.  422.— Dogiel.  Arch. 
/.  mik.  Anat.,  1889,  XXXIII,  4,  p.  440. — Bonnet.  Grundriss  der  Entwick. 
der  Haussdugethiere,  1891. — Regaud.  Origine  des  vaisseaux  lymphatiques 
de  la  mamelle.  C.  R.  Soc.  Biol.,  1894,  n°  20,  p.  495  ; — Etude  histologique 
sur  les  vaisseaux  lymphatiques  de  la  glande  mammaire.  Journ.  Anat.  et  Phys., 
1894,  XXX,  n°  6.— Ranvier.  Chyliferes  du  rat.  C.  R.  Acad.  Sciences,  1894, 
n°  12,  p.  621  ; — Developpement  des  vaisseaux  lymphatiques.  C.  R.  Academie 
dzs  Sciences,  30  dec.  1895,  p.  1105  ; — Circulation  de  la  lymphe.  C.  R.  Acad. 
Sciences,  1894,  CXIX,  n°  26. — Gley.  Innervation  des  vaisseaux  lymphatiques. 
Bull.  Museum  d'hist.  not.  Paris,  1895,  n°  3,  p.  127. — Regaud  et  Bar j on. 
Vaisseaux  lymphatiques  des  tumeurs  epitheliales  malignes.  C.  R.  Soc.  Biol., 
19  dec.  1896. — D'Abundo.  Voies  lymphatiques  du  systeme  nerveux  central. 
Arch.  ital.  biologie,  1895,  XXIII,  fasc.  1  et  2,  p.  151  ; — Annali  di  neurologia, 
1896,  p.  229. — Ranvier.  Morphologic  du  systeme  lymphatique.  De  1'origine 
des  lymphatiques  dans  la  peau  de  la  grenouille.  C.  R.  Acad.  Sciences,  1895, 
CXX,  n°  3,  p.  132  ; — Etude  morphologique  des  capillaires  lymphatiques  des 
mammiferes.  C.  R.  Acad.  Sciences,  1895,  121,  11°  24,  p.  856. — Goldscheider 
et  Flatau,  Zeitschr.  /.  klin.  Med.,  1896,  XXXI. — Gerota.  Zur  Technik  der 
Lymphgef  ass-injection.  Eine  neue  Injectionsmasse  fiir  Lymphgef  asse. 
Polychrom.  Injection.  Anat.  Anzeiger,  1896,  XII,  n°  8,  p.  216. — Timofejew. 
Ueber  die  Nervenendigungen  in  den  mdnnlichen  Geschlectorganen  des  Menschen 
u.  der  Sdugethiere,  1896. — Ranvier.  Sur  une  substance  colloi'de,  myelinoide 
claboree  par  les  lymphatiques  a  Fetat  normal.  C.  R.  Academie  Sciences,  1896, 
CXXII,  n°  8,  p.  428. — Boddaert.  Anat.  Anzeiger,  Suppl.  Band,  1897. — 
Ranvier.  Morphologic  et  developpement  du  systeme  lymphatique.  Archives 
d'anatomie  microsco pique,  I,  p.  137. — Dogiel.  Arch.  /.  mikrosk.  Anat.,  1897, 
XLIX. — Behre.  Zur  Frage  der  Lymphgefassneubildung.  Inaug.  Diss.  Kiel, 
1898. — Homen  et  Laitinen.  Zieglers  Archiv.  lena,  1899,  XXV,  I. — Guillain. 
C.  R.  Soc.  Biol.,  mai  1899. — Creighton.  A  system  of  peri  vascular  lymphatic 
cylinders  and  capsules  in  the  united  amnion  allantois  of  the  chick.  Journ. 
Anat.  Phys.,  XXXIII,  1899,  III. — Cuneo  et  Delamare.  Note  sur  1'histologie 
des  lymphatiques  de  1'estomac.  C.  R.  Soc.  Biol.,  mai  1900. — Regaud.  Origine 
das  vaisseaux  lymphatiques  de  la  glande  mammaire.  Relations  entre  la 
richesse  des  radicules  lymphaticules  et  la  facilite  plus  ou  moins  grande  du 
drainage  de  la  lymphe  dans  le  tissu  conjonctif.  Bibl.  Anat.,  1900,  VIII,  fasc.  4, 
p.  261. — Sala.  Sullo  sviluppo  dei  cuori  linfatici  e  dei  dotti  toracici  nell'  em- 
brione  di  polio. — Ousoff.  Les  vaisseaux  lymphatiques  du  diaphragme  et 
leurs  rapports  avec  la  cavite  abdominale  et  avec  le  processus  d'absorption. 
Arch,  russes  de  pathol.,  t.  7.  n°  3. — Binswanger  u.  Berger.  Beitrage  zur  Kentniss 
d.  Lymphcirculat.  in  der  Grosshirnrinde.  Arch.  f.  path.  Anat.  u.  Physiol.,  CLII, 
3. — Dalla  Rosa  H.  Lymphgef  assinject.  Verhandl.  der  anat.  Gesellsch.,  1900. — 
Renaut.  Note  sur  les  capillaires  lymphatiques  du  tissu  conjonctif  lache. 
Assoc.  des  Anatomistes.  Lyon,  1901,  p.  223. — Kytmanoff.  Ueber  die  Ner- 
venendigungen in  den  Lymphgef  assen  der  Saugethiere.  Anat.  Anzeig.,  6  juin 
1901,  n°  15. 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM     81 


LYMPHATIC    GLANDS. 

HISTORICAL  REVIEW. — The  lymphatic  glands,  known  since  the  most  ancient 
times,  were  for  a  long  time  rego.rded  as  closed  glands,  and  allied  to  the  thymus 
and  thyroid  body  ;  they  constituted  a  part  of  the  conglobate  glands  of  Sylvius 
and  Wharton.  It  was  thought  they  modified  the  iymph.  VVharton  and 
Bnrtholin  considered  that  they  retained  a  part  of  the  latter;  whereas 
de  Graaf  and  Malpighi,  thought  that  they  added  to  it  the  products  of  their 
secretion. 

In  support  of  these  opinions,  the  differences  shewn  to  exist  between  the 
afferent  and  efferent  lymph,  the  considerable  slowing  of  the  glandular  circula- 
tion, and  also  the  direct  communications  between  the  white  vessels  and  the 
bloodvessels,  were  adduced  as  evidence.  Later  on,  Neumann  firmly  believed 
that  the  mesenteric  glands  which  were  placed  on  the  channels  in  which 
intestinal  absorption  was  taking  place,  were  bound  to  take  some  part  in  the 
nutritive  metabolism  of  the  organism  ;  he  thought  that  these  glands  must 
transform  matter  coming  from  without,  into  internal  or  living  substance. 
These  physiological  hypotheses  were  forgotten  when  anatomy,  and  especially 
histology,  had  raised  other  problems.  Anatomists  believed  that  the  gland 
was  simply  a  plexus  of  lymphatic  vessels.  This  opinion,  which  was  held 
by  Hewson,  Cruikshanks  and  Mascagni,  was  shared  by  Lauth,  Breschet, 
and  Richet.  In  Germany,  the  term  lymphatic  gland  has  been  retained 
through  custom  ;  but  in  France,  the  term  ganglion,  given  by  Chaussier,  has 
been  preferred,  seeing  that  Soemerring  had  found  a  rough  resemblance  between 
the  nervous  and  lymphatic  ganglia. 

After  Henle,  Noll  and  Briicke  had  demonstrated  the  existence  of  the  glandu- 
lar substance,  which  had  been  suspected  by  Bichat,  Cruveilhier  and  Beclard, 
histologists  were  compelled  to  describe  its  texture,  and  to  determine 
the  relations  which  existed  between  the  leucocytes  and  the  connective 
tissue. 

Cells  and  a  network  were  seen  ;  the  cells  strangely  resembled  leucocytes, 
and  the  fibrillary  network  was  not  without  apparent  analogy  to  that  of 
ordinary  connective  tissue.  Did  this  as  a  whole,  it  was  asked,  correspond 
to  a  new  tissue,  or  did  it  result  from  the  association  of  two  elements  which 
were  in  other  places  known  to  be  distinct  and  isolated,  namely,  the  leu- 
cocyte and  connective  tissue  ?  The  likeness  was  GO  striking  that  all,  with 
the  exception  of  Robin,  admitted  that  the  glandular  cells  were  leucocytes, 
or,  at  any  rate,  were  produced  from  leucocytes. 

It  is  true,  the  origin  of  these  elements  was  discussed.  Sertoli,  Bonnet,  Conil 
and  Retterer  thought  they  were  autochtonous,  and  derived  from  the  sur- 
rounding mesoblastic  cells ;  Gulland,  Larroque,  Chiewitz,  Ranvier,  Champeil, 
Chandelux,  Renaut,  and  Saxer  considered  they  were  leucocytes  which  had 
wandered  into  the  meshes  of  the  connective  tissue. 

The  leucocytic  origin  of  the  cells  of  the  lymphatic  gland  once  admitted, 
then  the  efforts  of  histologists  necessarily  had  to  be  directed  towards  the 
study  of  the  reticulum,  termed  by  Koelliker  the  cytogenous  tissue,  by  His 
the  adenoid  tissue,  and  by  Frey  the  reticular  tissue. 

To  determine  whether  they  were  dealing  with  connective  tissue, 
iibrillee,  or  prolongations  of  anastomosing  cells,  it  was  essential  to  arti- 
ficially remove  the  foreign  cells  which  infiltrated  the  glands.  With  this  object, 
Henle  macerated  the  glands  in  water  or  liquor  potassae,  after  previously 
•drying  them  ;  and,  since  then,  pepsin  and  trypsin  have  been  used.  His 


82  THE    LYMPHATICS 

devised  the  mechanical  process  known  as  pencilling.  For  a  long  time  the 
results  furnished  by  these  crude  methods  were  accepted  without  question  ; 
the  results,  however,  did  not  agree. 

Henle,  Baumgarten,  Ellenberger,  Sussdorf,  Bizzozero,  Lowit,  Ranvier, 
Reliant,  Klein,  Heiderihain,  Stohr,  Gulland,  Hoyer,  Hoehl,  Mall  maintained 
that  the  reticulum  was  purely  fibrillary ;  while  Eckard,  Leydig,  His,  Frey, 
Koelliker,  Billroth,  Rollett,  Krause,  Toldt,  Orth,  Schoefer,  Schenk,  Saxer, 
Gegenbaur,  Chiewitz,  Schieferdecker,  Forster,  and  Huxley  thought  it  was 
composed  of  a  cellular  network,  that  is  to  say,  it  was  formed  by  the  anastomosis 
of  cellular  prolongations.  There  are  still  the  same  divergences  of  opinion 
as  to  the  nature  of  this  reticulum.  Amongst  the  upholders  of  the  fibrillar 
theory,  some  maintain  that  the  reticulum  is  made  up  of  ordinary  connective 
tissue,  on  the  fibres  of  which  endothelial  cells  are  placed  ;  others  believe 
that  it  is  composed  of  certain  fibrillae,  which  are  histochemically  different 
from  connective  tissue  and  elastic  tissues. 

In  fact,  Recklinghausen  has  shown  that,  unlike  elastic  fibres,  these 
fibrillae  do  not  resist  the  action  of  acids  and  alkalies  (soda  and 
potash). 

Orth  has  stated  that  they  do  not  swell  up  with  acetic  acid  as  is  the  case 
with  connective-tissue  fibres  ;  Mall  has  found  that  they  resist  the  action  of 
trypsiri  longer  than  the  latter,  and  that  when  heated  they  do  not  yield  gelatin. 
This  reaction  and  the  mesodermic  origin  of  the  reticulum  identify  it  with  em- 
bryonic connective  tissue  ;  but,  as  the  tissue  develops,  and  becomes  subjected 
to  different  kinds  of  morbid  influences,  and  as  age  advances,  variations  in  its 
fibrous  and  elastic  tissues  are  produced  (Melnikow — Raswedenkow,  Retterer). 
There  is  present  then,  at  the  same  time,  a  reticulum  composed  of  cells,  and 
fibrous  arches  which  are  capable  of  supporting  the  endothelial  cells ;  this  was 
seen  by  Miiller,  Ribbert,  Demoor,  Sisto  and  Morandi.  Therefore,  those 
who  held  that  the  network  was  fibrillary,  and  those  who  maintained  it 
was  cellular,  were  both  right,  but  knowing  only  a  portion  of  the  truth, 
they  were  wrong  in  generalizing  their  opinions  and  in  regarding  them  as 
antagonistic. 

During  this  time,  the  knowledge  of  glandular  leucopoiesis  was  becoming 
established.  In  1851,  Heyf elder  stated  that  the  white  corpuscles  were  much 
more  numerous  in  the  efferent  than  in  the  afferent  vessels ;  Briicke  and  Frey 
confirmed  this  observation.  Later  on,  after  finding  numerous  mitoses  in  the 
germinatival  centres  of  the  young  or  hypertrophied  gland,  Arnold,  Bizzozero, 
Flemmirig,  Panlsen,  Lowit,  Hofmeister  and  Miiller  showed  the  mechanism  of 
this  leucopoiesis  ;  the  reality  of  the  process  was  afterwards  confirmed  by 
experimental  and  histo-pathological  facts. 

We  must  observe  however  that,  some  authors,  convinced  of  the  exogenous 
origin  of  the  cells,  regard  the  gland  not  so  much  as  cytogenous  in  character  as 
a  place  for  the  formation  of  leucocytes.  This  manufacturing  centre  is  accessory, 
whereas  the  dilatation  of  lymphatic  vessels  is  of  fundamental  importance. 
Ranvier  too,  thinks  that,  "  the  gland  should  be  regarded  simply  as  a  pocket 
— a  sort  of  bladder — in  which  the  lymph  circulates  after  it  has  passed  out  of 
the  afferent  and  before  it  passes  into  the  efferent  vessels."  It  is  curious 
to  reflect  that  fifty  years  of  histology  should  have  given  rise  to  this  opinion, 
which  so  closely  resembles  that  held  by  the  anatomists  of  the  eighteenth 
century. 

Granted  leucopoiesis,  the  question  still  remains  as  to  what  kinds  of 
leucocytes  are  manufactured  by  the  gland.  The  glandular  cells  have  been 
studied  by  Arnold,  Flemming,  Hoyer,  Schumacher,  Benda,  etc. 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM     83 

After  that,  attention  was  drawn  to  the  histo-f unctional  parallel  of  the  gland 
to  the  spleen  and  marrow  of  bone.  According  to  some,  haematopoiesis,  the 
production  of  granular  amoebic  cells  and  phagocytes,  belongs  to  the  marrow; 
haematolysis,  and  as  an  accessory,  haematopoiesis,  to  the  adult  spleen, 
whereas  the  functions  of  the  gland  are  confined  to  the  production  of 
lymph-cells. 

Others  think  these  organs,  which  appear  so  highly  differentiated,  were 
originally  fused.  On  the  one  hand,  Papperiheim  and  Dominici  have  found 
leucocj'tes  in  the  marrow  of  bones,  while  on  the  other,  Metchnikoff,  Lacroix 
andRenaut,  Rawitz  and  Demoor,  have  described  giant  cells  in  the  lymphatic 
gland.  Hoyer,  Schafer,  Kanter  and  Labbe  have  studied  the  eosinophiles, 
Dominici  the  amphophiles.  On  the  other  hand,  the  haematopoietic  and 
haematolytic  functions  must  be  admitted.  In  the  list  of  those  who  have 
worked  at  glandular  haematolysis  are  inscribed  the  names  of  Hover,  Koeppe, 
Gabbi,  Schumacher,  Masslow,  Thome,  Sisto  and  Morandi,  Scott  Wartliin; 
while  glandular  haematopoiesis  has  been  made  the  special  object  of  study  in 
the  works  of  Rindfleisch,  Weigert,  Neumann,  Lowit,  Kultschitzky,  Lockart 
Gibson,  Moses  Grunberg,  and  Retterer. 

Now,  our  knowledge  of  leucocytic  ferments,  and  that  of  certain  glandular 
ferments  (amylase,  lipase,  plasmase,  the  enterokynase  of  Delezenne,  the 
macrocytase  of  Tarassewitch)  gives  us  reason  for  thinking  that  the  old 
anatomists  and  Robin  were  not  wrong  in  conceiving  the  existence  of  a  secre- 
tion in  the  glands  which,  perhaps,  might  manifest  itself  histologicaliy 
by  the  phenomena  of  cell  destruction. 


Having  now  indicated  the  general  macroscopical  characters 
(form,  consistence,  etc.)  of  the  lymphatic  glands,  we  will  study 
their  development,  structure  and  functions. 

MACROSCOPIC  CHARACTERS. — Form.  At  times  flat,  at  others 
elongated  or  cylindrical,  the  lymphatic  glands  are  often  prismatic 
or  irregularly  spherical,  or  more  or  less  rounded  or  oval  ;  some- 
times they  resemble  a  horse  shoe  (Cornil)  ;  they  are  nearly  al- 
ways reniform.  The  oblique  afferent  lymphatics  approach  their 
convex  border  ;  whereas  the  efferent  vessels,  which  are  larger 
and  more  numerous,  escape  from  the  hilum  on  their  concave 
border. 

Consistence. — The  glands  are  not  soft,  but  of  a  somewhat  firm 
and  elastic  consistence.  Sappey  compares  their  feel  to  that  of  the 
liver,  and  Richet  to  that  of  the  kidney. 

Colour. — This  varies  in  different  regions,  physiological  states,  and 
in  different  animals.  In  man,  as  we  know,  the  bronchio-tracheal 
glands  are  infiltrated  with  small  particles  of  carbon,  and  are  coloured 
black  ;  those  of  the  liver  are  yellow,  whereas  those  of  the  spleen 
are  brown.  The  mesenteric  glands,  which  are  rosy-white,  become 
whitish  during  digestion.  In  the  horse,  and  the  ox,  the  central 
portion  is  brown  ;  in  the  rabbit,  a  more  or  less  pronounced 


84  THE    LYMPHATICS 

greenish  yellow  tint  is  often  found  in  some  of  the  glands  which 
constitute  the  pancreas  of  Aselli.  The  usual  tint  of  normal  glands 
seems  to  be  about  rosy- white.  It  is  difficult  to  state  the  exact 
morphological  significance  of  the  haemo-lymphatic  red  glands,  which 
have  been  studied  by  Gibbes,  Robertson,  Clarkson,  Vincent  and 
Harrison,  Drummond,  Haberer,  Scott  Warthin,  Morandi  and 
Piato.  They  seem  to  be  present  not  only  in  man,  in  the  pararenal 
and  vertebral  regions,  but  also  in  the  horse,  the  sheep,  the 
goat,  the  pig,  the  calf,  the  ox,  the  rat,  the  turkey  and  the  owl. 
If,  as  Scott  Warthin  thinks,  they  have  no  afferent  lymphatics, 
it  is  probable  that  they  perform  the  functions  of  accessory 
spleens. 

Dimensions. — Even  in  the  same  individual,  the  size  of  the  glands 
varies,  physiologically,  within  wide  limits  :  while  the  larger  are 
the  size  of  an  olive  or  even  larger,  the  smallest  are  invisible  to 
the  naked  eye.  Letulle  has  described  microscopical  glands  in  the 
wall  of  the  stomach  ;  Gulland  in  the  axilla  ;  and  in  the  mesentery 
there  are  numbers  of  them.  These  glands  under  different  physio- 
logical or  morbid  influences,  may  become  enlarged.  Stiles  has  seen 
axillary  glands  appear  during  lactation  and  disappear  on  its 
cessation. 

The  glands  tend  to  get  smaller  as  age  advances.  They 
become  so  small  in  the  aged  that  Cruikshanks,  Mascagni, 
Ruysch  and  Haller  believed  that  they  completely  disap- 
peared. 

The  existence  of  these  microscopical  glands  would  be  sufficient  in 
itself  to  render  numerical  estimates  laid  down  by  anatomists  ex- 
tremely speculative,  but  there  is  another  reason  which  renders  such 
estimates  valueless,  viz.,  the  existence  of  diffuse  or  circumscribed 
lymphoid  formations  (lymphatic  points,  amygdalae,  Peyers  patches, 
etc.)  which,  so  many  morphological  and  functional  affinities  connect 
with  the  glands.  Without  here  speaking  of  embryological  differ- 
ences, elsewhere  discussed,  we  may  add  that  there  is  only  one 
difference  between  the  amygdalae  and  the  glands,  namely,  that 
whereas  the  lymphatics  traverse  the  gland,  they  actually  arise  in 
the  amygdala?,  which  from  this  point  of  view  is  comparable  to  the 
spleen. 

Number. — Sappey  estimates  the  number  of  apparent  glands 
as  from  6  to  700  approximately ;  others  from  4  to  600.  There 
is  an  inverse  relation  between  the  number  and  the  volume  of  the 
glands  :  the  surmulot  (Norway  rat),  the  hedgehog,  the  dog,  the 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM     85 

daman,1  the  antelope,  the  seal,  the  dolphin,  have  few  but  voluminous 
glands  :  man  has  a  larger  number  of,  but  proportionately  smaller 
glands.  This  latter  type  seems  to  us  to  be  the  perfected  form.  It  is 
interesting  to  note  that  this  relation  between  the  size  and  the 
number  exists  not  only  in  the  animal  series,  but  even  in  the  same 
individual.  To  convince  ourselves  of  this  fact,  we  need  only  com- 
pare the  glands  in  different  parts  of  the  human  body  :  sometimes 
we  find  they  are  large  and  scarce  ;  sometimes  small  and  numerous. 
Thus,  in  a  given  animal  and  in  a  given  region,  the  quantity  of  glandular 
substance  is  always  practically  identical. 

Situation. — The  glands  are  almost  always  buried  in  a  bed  of 
adipose  connective  tissue.  They  are  adherent  only  to  a  very 
slight  extent,  and  are  movable  under  the  finger.  In  the  limbs, 
they  are  termed  superficial  or  deep,  according  to  their  situation, 
either  above  or  below  the  aponeurosis.  Generally  speaking,  they 
are  more  numerous  on  the  flexor  aspect. 

Sometimes  they  are  solitary,  but  are  more  often  united  in  groups  of 
from  three  to  six,  or  even  from  ten  to  fifteen  ;  they  form  chains  or 
chaplets.  According  to  Sappey,  their  situation  is  by  no  means 
fixed.  In  reality,  in  spite  of  somewhat  wide  variations,  they  are, 
speaking  generally,  para-vascular.  In  the  limbs,  they  are  arranged 
close  to  the  vasculo-nervous  bundles  ;  in  the  abdomen,  they  are 
grouped  round  the  aorta,  and  the  inferior  vena  cava.  The  spleen 
is  clearly  peri-vascular. 

The  lymphoid  masses  are  in  preference  para-epithelial.  They 
are  arranged  on  the  circumference  of  the  epithelium  of  the  digestive 
track,  sometimes  even  on  the  periphery  of  the  hepatic,  pancreatic, 
and  supra-renal  epithelium.  We  know  that  the  diffuse  lymphoid  form- 
ations of  batrachians  are  peri- vascular,  peri -renal  or  peri-hepatic. 
Similarly,  the  lymphatic  glands  of  invertebrates  are  sometimes 
peri-nervous  (scorpions),  and  peri-digestive  (oligochetae),  and  more 
frequently,  peri-vascular  (cephalopods). 

It  should  be  observed  that  according  to  Cuenot,  the  Echinoderms 
and  the  Trochozoa,the  Bryozoa,  and  the  Polychetae,  actually  combine 
the  two  cytogenous  glands,  namely  the  lymphatic  and  genital,  in 
one  structure. 

In   fact,  lymphoid  formations,  whether  diffuse  or  circumscribed, 


1  A  small  hyracoidean  hoofed  mammal  (genus  Hydrax)  with  rhinoceros- 
like  molar  teeth,  especially  Hydrax  Syriacus  of  Asia  Minor,  which  is 
probably  the  cony  of  the  Scriptures. 

G 


86  THE    LYMPHATICS 

are  systematized  by  a  relation  to  some  other  organ  ;  this  organ 
varies,  and  in  man  where  the  lymphatic  apparatus  attains  its 
maximum  complexity  and  extension,  the  systematization  is  at  the 
same  time,  para- vascular  and  para-epithelial. 

According  to  Stahr,  the  lymphatic  vessels  in  a  given  region  pass 
through  three  distinct  glandular  stages  during  their  course.  First 
of  all,  there  are  the  small  nodules  of  interrupted  glands  (Sclialtdriiseri) 
whose  presence  is  inconstant,  and  number  variable,  and  which  are 
always  unaffected  by  injections  ;  then,  come  the  regional  glands 
(Regionardriisen),  where  the  glands  are  larger  and  more  constant. 
Finally,  there  are  the  intermediary  glands  (Intermediariisen). 

There  are  transitional  forms  between  the  "  Schaltdriisen " 
and  the  regional  glands  :  such  are  the  epitrochlear,  and  anterior 
tibial  glands.  But  as  Cuneo  has  observed,  such  a  gland  which 
may  be  intermediate  for  the  cutaneous  lymphatics  of  the  face, 
becomes  regional  for  those  of  the  tongue.  Stahr's  classification 
has  therefore  only  a  relative  value,  and  for  this  reason  Cuneo 
only  recognizes  a  first  and  a  second  class  of  glands. 

The  knowledge  of  these  relays  of  glands  placed  in  succession  one 
behind  the  other  in  the  lymph  stream,  is  interesting  from  a  patho- 
logical point  of  view,  for  they  constitute  so  many  stages  at  which  the 
spread  of  infections  and  cancers  is  temporarily  arrested. 

DEVELOPMENT. — Though  lymphatic  glands  exist  in  invertebrates, 
and  lymphoid  masses  in  the  lower  vertebrates,  the  phylogenic 
appearance  of  the  gland  properly  so  called  is  somewhat  slow. 
It  is  seen  in  the  cervical  region  in  some  birds  ;  and  it  develops 
to  a  greater  extent  though  it  still  remains  rudimentary  in  certain 
mammals,  such  as  the  pig.  Nevertheless,  the  ontogenic  development 
of  this  highly  specialized  gland  is  less  slow  than  Breschet  imagined 
it  to  be.  This  anatomist  found  no  trace  of  it  in  the  human  foetus 
of  six  months.  On  the  other  hand,  Renaut  has  seen  well-developed 
glands  at  the  fifth  month  of  intra-uterine  life.  In  man,  Conil  has 
described  them  as  always  present  on  the  165th  day  of  gestation. 
Labbe  has  found  relatively  large  glands  on  the  90th  day.  In  the 
neck  of  the  human  foetus  of  four  months,  I  have  seen  very  unequally 
developed  glands  lying  side  by  side.  In  the  inguinal  region  of  the 
guinea  pig,  Retterer  has  observed  the  rudiments  of  a  gland  from  the 
35th  to  the  40th  day  of  gestation. 

On  the  other  hand,  certain  infants  born  at  seven  or  eight  months 
and  who  died  a  few  days  afterwards,  shewed  large  and  but  little 
differentiated  mesenteric  glands,  with  the  rudiment  of  a  cavern- 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM  87 


ous  sinus,  but  no  follicles.  Similarly,  in  young  animals,  side  by  side 
with  the  fully-developed  glands,  rudimentary  lymphoid  formations 
are  found.  Are  we  here  dealing  with  old  rudiments  whose  develop- 
ment has  been  arrested  or  retarded  ?  or  with  new  organs  in  process  of 
growth  ?  Both  suppositions  are  legitimate  ;  if  we  adopt  the  latter,  we 
may  suppose  that  there  are  some  glands  which  make  their  appearance 
very  late.  In  either  case,  it  is  quite  certain  that  the  formation  of 
the  glands  takes  place  later  than  that  of  the  lymphatic  vessels. 
This  statement,  already  made  by  Lauth,  Breschet,  Teichmann,  Engel 
and  Sertoli  has  been  confirmed  by  Ranvier. 

The  primitive  nodule  is  highly  vascularized.  His  laid  stress 
on  its  hyperaemia,  and  since 
then,  Ranvier,  on  account 
of  its  red  tint  has  compared 
it  to  a  piece  of  sealing  wax. 
This  primitive  nodule,  which 
is  formed  of  cells  heaped  up 
one  against  the  other,  is 
homogeneous  ;  it  presents 
neither  lacunae  nor  cavities, 
except  at  the  periphery 
where  endothelial  spaces 
(lymphatic  vessels)  are  seen 
in  section.  The  origin  of 
these  cells  which,  by  their 
agglomeration  constitute  the 
original  nodule  has,  as  we 
know,  been  the  subject  of 
discussion. 

Many  authors  think  that  it  is  a  case  of  leucocytes  having  wandered 
into  the  meshes  of  the  connective  tissue  ;  this  opinion  only  rests 
on  indirect  evidence,  such  as  the  pre-existence  of  vessels  and  of 
white  corpuscles,  and  the  amoebism  of  the  latter.  Owing  to  their 
oxyphilism,  leucocytes  would  be  attracted  by  their  future  germin- 
alival  centres,  which  are  highly  vascularized  and  very  oxygenated. 
Finally,  as  fine  colouring  matters  can  penetrate  the  follicle,  we  may 
suppose  that  amoebic  leucocytes  can  do  the  same. 

Others,  on  the  contrary,  think  it  is  a  case  of  autochtonic  cells 
which  have  originated  from  mesodermic  elements. 

Let  us  now  study  the  final  modifications  of  this  simple  and 
hitherto  homogeneous  rudiment.  At  first,  it  looks  like  a  large 


Fio.  19. — Cervical  glands  of  a  four  months'  human 
foetus.  Above,  the  gland  is  homogeneous,  and 
surrounded  by  a  peripheral  lymphatic  sinus  ; 
below,  the  process  of  cavernization  has  com- 
menced. 


88  THE    LYMPHATICS 

lymphatic  sinus,  divided  into  compartments  by  trabeculae  ;  this 
vessel  runs  round  the  edge  of  the  nodule,  and  separates  it  from 
the  connective  tissue  capsule,  which  now  becomes  quite  distinct  from 
it.  Then,  the  lymphatic  channels  in  the  course  of  their  development, 
penetrate  one  of  the  extremities  of  the  homogeneous  nodule.  These 
vessels  isolate  segments  of  the  glandular  substance  :  the  vessels  we 
will  call  cavernous  sinuses,  and  the  irregular  glandular  andanastomotic 
segments,  follicular  cords.  The  whole  constitutes  the  central  or 
medullary  part  of  the  organ. 

The  peripheral  part  which  is  still  homogeneous,  corresponds 
to  the  cortical  substance.  It  is  the  intermediate  tissue  (Zwischengewebe) 
of  Schumacher,  and  the  reticulated  sheet  of  Bezancon  and  Labbe. 
In  this  homogeneous  sheet,  oval  formations  appear — the  nodules 
or  cortical  follicles  ;  then,  prolongations  from  the  capsule,  and  the 
advancement  of  lymphatics,  which  establish  communications 
between  the  peripheral  sinus  and  the  cavernous  channels, 
divide  this  hitherto  homogeneous  mass  into  segments.  Though 
the  development  of  the  gland  is  not,  as  the  old  anatomists 
thought,  limited  to  that  of  the  white  vessels,  yet  we  may 
say,  that  its  histological  appearances  are  largely  subordinated  to 
the  more  or  less  precocious  and  more  or  less  extensive  penetration 
of  the  gland  by  lymphatics.  Just  as  the  liver  is  overrun  by  blood 
vessels,  so  is  the  gland  by  lymphatic  channels. 

How  are  the  lymphatic  vessels  developed  here  ?  According  to 
Engel,  they  divide  into  two  ;  their  branches  multiply  and  become 
sinuous,  while  in  their  intervals,  the  glandular  substance  makes  its 
appearance. 

According  to  Ranvier,  in  the  region  of  the  nodule,  the  lymphatic 
vessel  is  interrupted  by  a  regression  or  partial  atrophy.  Two  trunks 
are  formed,  a  superior  and  an  inferior,  the  future  efferent  and 
afferent  vessels.  The  inferior  segment  of  the  lymphatic,  thus  cut 
off,  terminates  in  a  cul-de-sac.  This  cul-de-sac  buds  and  penetrates 
the  vascular  nodule.  So  far,  lymph  cannot  permeate  the  gland, 
seeing  that  liquid  injected  by  the  afferent  does  not  pass  into  the 
efferent.  Eventually,  however,  this  communication  is  established, 
and  then,  says  Ranvier,  the  gland  is  comparable  to  a  simple 
angeioma.  It  soon  becomes  transformed  into  a  cavernous  angeioma, 
for  the  different  buds  of  lymphatic  capillaries  become  confluent. 
The  chief  obstacle  to  the  indefinite  extension  of  this  process  of 
cavernization  is  effected  by  the  blood  vessels. 

This  development  of  glandular  lymphatics  has  raised  anew  the 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM  89 

question,  previously  discussed,  as  to  whether  their  lumen  represents 


Medulla 


FIG.  20. — The  mesentoric  glnnd  of  the  dog. 

an  inter  or  an  intra-cellular  space.  We  know  that  Koelliker,  and 
subsequently  Leydig  and  Virchow,  believed  in  communications  be- 
tween the  lymphatic  cavity  and  the  cavity  of  connective  tissue  cells. 
Klein  maintained  that  the  first  rudiment  of  the  lymphatic  lumen 
was  represented  by  an  intra-cellular  vacuole  ;  similarly,  Retterer 
believed  that  the  cavity  of  the  lymphatic  vessel  resulted  from  a 
liquefaction  of  part  of  the  cell  body,  and  the  process  of  cavernization 
of  the  gland  is  identical  with  this.  To  understand  why  such  appar- 
ently different  views  are  held,  we  need  only  remember  that  for  those 
who  uphold  the  intra-cellular  origin,  the  elements  of  the  glandular 
rudiment  have  no  precise  limits,  and  constitute  a  vast  plasmodium. 
Thus,  "Retterer  speaks  of  the  "  full  tissue  "  of  the  gland,  as  a 
protoplasmic  layer  strewn  with  nuclei.  The  "inter-nuclear 
substance  "  soon  shows  two  differentiations ;  close  to  the  nuclei,  it 
remains  homogeneous,  and  stains  feebly  with  the  colouring  acids  ; 
this  is  the  hyaloplasm  which  is  broken  up  by  irregular  undulating 
tracts,  which  can  be  stained  with  haematoxylin.  These  tracts 
constitute  the  chromophile  reticulum  in  the  meshes  of  which  we 
find  the  hyaloplasm.  The  chromophile  reticulum  produces  elastic 
fibres.  After  swelling  up,  the  hyaloplasm  becomes  vacuolated ; 
remains  of  cells  (leucocytes  and  cells  which  have  undergone  the 
haemoglobic  degeneration)  are  set  free.  Later  on,  in  places,  the 
remains  of  this  hyaloplasm  may  be  seen  giving  birth  to  well 
developed  connective  tissue  fibrillae  of  collagen. 


90  THE    LYMPHATICS 

STRUCTURE. — The  gland  is  surrounded  by  a  connective  tissue 
capsule  which,  in  almost  all  animals,  sends  out  prolongations  towards 
the  interior  of  its  parenchyma.  If  at  this  stage,  a  section,  even 
under  a  low  power,  is  examined,  it  is  quite  easy  to  recognize  that 
the  appearance  of  the  glandular  tissue  varies  in  the  centre  and  at 
the  periphery. 

The  peripheral  or  cortical  portion  (cortical  substance),  appears 
as  a  homogeneous  layer  at  the  bottom  of  which  rounded  formations, 
the  follicles,  are  visible.  In  the  central  or  medullary  part  (medullary 
substance),  irregular  cords  separated  from  each  other  by  clear  spaces 
may  be  seen  :  the  medullary  cords  are  separated  from  the  cortical 
part ;  the  clear  intermediate  spaces  are  the  lymph  channels,  the 
cavernous  sinuses. 

We  will  now  study  the  structure  of  each  of  these  parts  in  turn  : — 

1.  The  capsule. 

2.  The  cortical  zone. 

3.  The  medullary  zone. 

The  Capsule. — This  is  somewhat  thin  in  the  hedgehog,  the  rabbit, 
and  especially  in  the  guinea-pig,  but  it  is  more  marked  in  the  dog 
and  adult  man.  Fairly  often,  it  increases  in  size  and  forms  a 
fibrous  nucleus  at  the  hilum. 

It  is  composed  of  fibres,  connective  tissue  cells,  and  fine  elastic 
networks,  and  in  certain  animals  (mouse,  ox,  and  horse,)  at  its 
deepest  part,  it  contains  delicate  muscular  fibres.  According  to 
Renaut,  muscular  fibres  are  absent  in  the  sheep  and  in  man. 
At  intervals,  from  the  inner  surface  of  this  capsule,  partitions 
arise,  traversing  the  cortex  ;  after  successive  divisions,  they  gain 
the  central  part,  and  sometimes  even  reach  the  hilum.  These 
fibre-muscular  prolongations  which  are  well  marked  in  the  ox  and 
dog,  are  not  so  plain  in  the  rabbit ;  they  are  almost  entirely  absent 
in  the  guinea-pig.  Externally,  the  capsule  is  continuous  with  the 
meshes  of  the  cellulo-adipose  tissue  which  surrounds  it ;  within,  it  is 
almost  entirely  separated  from  the  glandular  substance,  by  a  space 
whose  dimensions  are  somewhat  irregular  (peripheral  lymphatic 
sinus). 

In  places,  the  cavity  of  this  sinus  is  narrowed  by  the  embossments 
of  the  glandular  cortex  ;  at  certain  points,  it  disappears  entirely 
and  the  peripheral  part  of  the  gland  touches  the  capsule.  This 
sinuous  cavity  is  traversed  by  fibro-muscular  arches  which  spring 
from  the  capsule,  and  on  the  surfaces  of  which  may  be  seen  some 
endothelial  cells.  In  the  interior  of  the  lymphatic  canal,  large  star- 


GENERAL  ANATOMY  OP  THE  LYMPHATIC  SYSTEM   91 

shaped  cells  may  be  seen,  whose  filiform  prolongations  anastomose 
with  each  other,  and  form  a  network  which  loses  itself  in  the  capsule 
and  in  the  cortical  layer.  The  nucleus  of  these  elements  is  some- 
times rounded,  more  often  elongated,  and  almost  always,  somewhat 
poor  in  chromatin. 

The  peripheral  sinus  contains  microcytes,  and  macrocytes,  some 
eosinophiles,  and  some  red  blood  cells. 

Cortical  Portion  (Cortical  substance). — Below  the  sinus  there  is 
visible  a  large  horse-shoe,  the  arms  of  which  do  not  reach  as  far 
as  the  hilum  :  this  is  the  cortical  part  which  always  diminishes 
or  disappears  before  reaching  the  hilum  of  the  organ.  It  thus 
encloses,  within  its  concavity,  the  medullary  part  which  is  continued 
up  to  the  hilum. 

Though  relatively  small  in  the  dog,  the  cortex  is  much  more 
marked  in  the  hedgehog,  the  rat,  the  guinea-pig  and  the  rabbit. 
In  these  animals,  it  forms  a  homogeneous  mass  which  occupies 
nearly  the  whole  of  the  organ,  excepting  the  immediate  vicinity  of 
the  hilum.  Moreover,  in  the  same  subject,  the  less  developed  the 
gland,  the  further  does  the  cortex  extend. 

The  cortex  (intermediary  tissue  of  Schumacher,  reticulated  layer 
of  Labbe)  is  made  up  of  a  number  of  cells  whose  outlines  are  some- 
what difficult  to  make  clear.  Fixation  with  Flemming's  strong 
solution  alone,  shows  the  cell  boundaries,  and  proves  that  it  is  not  a 
true  plasmodium.  Between  the  cells,  may  be  seen  filaments  well 
stained  by  all  the  plasmatic  colouring  agents  (light  green  and 
acid  fuchsin  of  Biondi's  mixture,  etc).  With  van  Gieson's  mixture, 
these  filaments,  unlike  adult  connective  tissue,  take  picric  acid, 
but  not  acid  fucshin.  Of  the  cells  of  the  cortical  layer,  the  majority 
are  small,  and  measure  from  5  to  8  p  ;  others  measure  from  9  to  15  p. 
The  nucleus  of  the  small  ones  is  rounded  or  quadrangular, 
and  possesses  a  somewhat  thick  chromatin  border ;  in  the  centre, 
one  or  two  rounded  or  elongated  chromatin  granules  are  found. 
Sometimes,  but  not  always,  a  true  nucleolus  is  found.  These  elements 
are  identical  with  the  microcytes  of  blood  and  of  lymph  (lymph- 
ocytes). 

The  large  cells  correspond  to  macrocytes.  Their  nucleus  is 
rounded,  or  oval,  and  sometimes  slightly  hollowed  out  along  one  of 
its  borders.  It  presents  a  fine  chromatin  border,  and  a  fine 
reticulum,  in  the  meshes  of  which  may  be  seen  one,  two,  or  even 
three,  pyrenosomes.  These  pyrenosomes  are  round,  elongated,  or 
slightly  constricted  ;  they  are  central  or  eccentric.  The  protoplasm 


92  THE    LYMPHATICS 

of  some  is  neutral,  while  that  of  others  is  either  basophile  or 
acidophile.  We  can  thus  easily  distinguish  in  the  cortical  layer 
some  large  elements,  whose  protoplasm  stained  with  orange  or  eosine, 
presents  vacuoles,  either  empty,  or  filled  with  cellular  debris,  or 
sometimes,  with  red  blood  cells  or  pigment  (mesenteric  gland  of  the 
rabbit). 

Here  and  there,  endothelial  cells  may  be  seen,  or,  at  least  cells 
which  are  endothelial  in  form,  whose  clear  elongated  nuclei  contain 
one  or  two  true  nucleoli,  and  wrhose  chromatin  appears  as  a  delicate 
network  or  fine  powder. 

In  the  cortical  layer,  we  may  find  eosinophiles  scattered  about, 
and  red  blood  cells  without  a  nucleus,  and  even  the  large  or  small 
cells  of  Neumann.  This  part  of  the  gland  is  very  poor  in  mitoses  ; 
but,  in  places  rounded,  oval  or  elongated  masses  of  variable  dimen- 
sions may  be  seen,  which,  arranged  in  one  or  two  rows,  project 
under  the  capsule  and  give  to  the  gland  its  irregular  bossed  appear- 
ance ;  these  are  the  cortical  follicles,  which  by  their  marked  agglom- 
eration, and  especially  by  the  special  disposition  of  their  peripheral 
cells,  encroach  upon  the  uniformity  of  the  cortical  layer. 

These   follicles    (alveoli,  ampullae,    glandular   nuclei,  nodosities, 

peripheral  nodules)  are  secondary  dif- 
ferentiations which  are  somewhat  slow  in 
appearing.  They  are  transitory  structures 
which  atrophy  and  entirely  disappear  in 
the  old.  Some  are  of  uniform  appearance, 
while  others  present  a  clear  centre  (clear 
spot  of  Briicke,  vacuole  of  His).  Freyhas 
observed  that  the  follicles  have  no  proper 

Fio.21.  —  Central  part   of  a  fol-  ,,         ,  ,.  , 

licie  of  the  mesenteric  gland  of     wall  ;  they  are  limited  by  the  endothehum 

the  rabbit  (fixed  with  Flem-       Qf   ft^  lymphatic     sinus,  which    SUlTOUllds 
ming  s  strong  solution):  peri- 

nuclear    vacuoles  ;    nuclear     them,      which    is     elsehere     inconstant. 


C°" 


are    easily   permeated    by    finely 
ground  matter,  or  by  liquids  injected  into 
the  lymphatic  channels. 

At  the  periphery  of  the  follicle,  the  microcytes  which  are  in  close 
contact  with  each  other  are  arranged  in  concentric  layers.  Here 
and  there,  a  larger  cell  may  be  seen  in  the  midst  of  them.  In  the 
centre,  microcytes  are  still  found,  but  the  macrocytes  predominate 
and  the  elements  are  much  further  apart  from  each  other.  All 
the  nuclei  are  not  rounded.  There  are  some  which  elongate  or 
curve  inwards  and  which  are  commencing  to  become  polymorphous. 


GENERAL    ANATOMY  OF  THE  LYMPHATIC  SYSTEM    93 


In  sections  coloured  with  haematoxylin-eosin.  and  safranin-green, 
the  protoplasm  is  generally  somewhat  feebly  stained  by  the 
staining  plasmatic  reagents.  With  Unna's  blue,  after  fixation  with 
sublimate,  it  may  easily  be  shown  that  some  of  the  macrocytes 
have,  like  the  myelocytes,  a  strongly  basophile  protoplasm. 

In  places,  the  body  cells  become  hollowed  out  by  the  peri-nuclear 
vacuoles.  Between  these  neighbouring  cavities  protoplasmic  bridges 
persist  in  the  form  of  fine  tracts  which  are  stained  by  eosin, 
and  the  acid  fuohsin  of  Biondi.  Sometimes,  but  not  always, 
this  protoplasmic  degeneration  is  accompanied  by  a  nuclear  degen- 
eration :  the  nucleus  becomes  reduced  to  one  or  several  rounded  or 
sickle-shaped  corpuscles,  which  can  be  highly  stained,  and  which 
are  homogeneous  or  perforated  by  a  central  aperture.  Elsewhere, 
these  colourable  corpuscles  are  very  numerous  and  very  small :  they 
form  a  mass  which  shows  up  clearly  on  the  lighter  background  of 
the  section.  There  are  some  which  occupy  the  digestive  vacuoles 
of  a  macrocyte,  and  which  are  the  sole  debris  of  a  phagocytic  cell. 
They  usually  stain  with  the  nuclear  stains  ;  some  of  them  take  the 
acid  fuchsin  of  Biondi. 

This  cytolysis  explains  the  presence  in  the  gland,  of  uric  acid, 
leucin,  tyrosin,  and  xanthin. 

But,  the  follicle  with 
the  clear  centre  is  essen- 
tially a  seat  of  cellular 
reproduction  ;  and 
Flemming  himself  has 
termed  it  the  germina- 
tival  centre.  It  was 
here,  in  fact,  that  the 
mitoses,  discovered  by 
Arnold  in  diseased 
glands,  were  again 
found  by  Bizzozero, 
Flemming,  Paulsen,  Lo- 
wi  t ,  Hof  meister  andMiil- 
ler,  in  normal  glands. 

Baumgarten  and  Ribbert  have  maintained  that  the  cells  which  ex- 
hibited karyokinesis  were  not  white  corpuscles,  but  were  mother  cells 
of  leucocytes.  Baumgarten  considered  they  were  of  the  nature  of  con- 
nective tissue,  while  Ribbert  thought  they  were  endothelial.  In  the 
adult,  this  karyokinesis  is  somewhat  rare  ;  but  it  is  increased  after 

G* 


FIG.  22. — Stained  corpuscles. 


THE    LYMPHATICS 


venaesection  and  after  splenectomy. 


e>£> 


lift 


?^>>*£<V.V     ^     „ 

^ 


FIG.  23. — Follicle  of  a  mesenteric  gland  of  tho 
guinea  pig.  Germinatival  centre  presenting 
mitoses. 


This  increase  is,  however, 
inconstant,  for  though  in 
the  opinion  of  Mayer,  Ben- 


:^!^%;^gP^         theopinionof  Mayer,  Ben- 
'^T-^ ^S^^^  t^W^Wi^      nett'Gerlach  and  Kourloff, 
^^%|^^rc/^'<C^^^^PSi      a   Slandlllar    hypertrophy 

follows  a  splenectomy,  this 
observation  has  not  been 
confirmed  by  Mosler  and 
Legros,  Masoin  and  Cere- 
sole.  In  the  rabbit,  some 
days  or  even  months  after 
splenectomy,  I  have  never 
found  a  manifest  hyper- 
trophy ;  the  mesenteric 
glands  were  of  normal 
colour  and  volume,  and 
their  follicles  presented 
no  unusual  number  of 
mitoses. 

Medullary  Portion  (me- 
dullary   substance). — The 

medullary  portion  of  the  gland,  which  is  more  or  less  completely 
surrounded  by  the  cortex,  presents  cords,  irregular  in  size,  course 
and  shape,  which  anastomose  with  each  other,  and  which  are  sepa- 
rated from  each  other  by  large  clear  spaces,  the  cavernous  sinuses. 

The  medullary  cords  (medul- 
lary utricles,  lymphatic  tubes, 
glandular  cylinders,  follicular 
cords),  which  are  central  pro- 
longations from  the  cortical 
layer,  are  formed  from  the  same 
cells,  which  are  here  sometimes 
less  agglomerated .  At  the  com- 
mencement of  the  medullary 
cords,  the  eosinophiles  are  more 
numerous.  Some  of  them 
have  a  single  round  nucleus, 
similar  to  that  of  the  non- 
granular  elements  ;  while  others 
are  somewhat  deficient  in 

i  T,      •  .1  i          ,  FIG.  24. — Medullary  cord  and  cavernous  sinus 

granules.       It     IS     possible,     but  of  a  meeenteric   gland   of  the  rabbit,    after 

rare    tO    find    them     in   mitosis.  intra-venous  injection  of  pilocarpine. 


FIG.  25. — Reticular  tissue  of  the  mesenteric  gland 
of  a  grey  rat  (fixed  with  alcoholic  acetic  sub- 
limate, without  pencilling.  (Dum.  oc.  3,  ob.  •r'.i). 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM    95 

Moreover,  this  part  of  the  gland  shows  karyokinesis  to  a  small 
extent.  Frequently,  it  may  happen  that  the  section  shews 
the  medullary  cords  like  the  malpighian  corpuscles  of  the 
spleen,  traversed  in  their  centre  by  an  artery. 

Between  the  cords,  the  cavernous  sinuses  afford  us  the  best 
spot  for  studying  pha- 
gocytosis of  the  gland, 
and  of  the  reticulum  ;  the 
latter,  as  can  easily  be  seen, 
is  formed  by  the  anasto- 
mosis of  cellular  prolonga- 
tions (vide  Fig.  25). 

Some  of  the  cells  of  the 
reticulum  have  a  rounded 
or  elongated  clear  nuc- 
leus, with  a  pyrenosome 
and  a  delicate  chromatin 
network  ;  others  have  sev- 
eral very  distinct  nuclei. 
In  their  acidophile  protoplasm,  are  digestive  vacuoles  in  which  the 
debris  of  leucocytes,  and  sometimes  red  corpuscles,  and  often  pig- 
ments, may  be  seen.  Between  the  large  star  shaped  cells  of  the  reticu- 
lum and  certain  round  and  free  macrocytes,  all  intermediate  forms 
seem  to  exist.  We  may  further  call  attention  to  the  existence  of 
giant  cells  with  a  budding  nucleus,  similar  to  those  in  the  bony 
marrow.  Rawitz  has  seen  them  in  the  monkey,  Demoor  in  the  cat. 

As  is  the  case  with  leucocytes,  microcytes  and  macrocytes  are 
always  present.  Some  nuclei  are  polymorphous.  According  to 
Labbe,  the  eosinophiles  are  very  numerous  in  the  guinea-pig  and 
in  the  rabbit,  but  very  rare  in  the  infant. 

I  have  never  found  them  very  abundant  in  the  cavernous  sinuses 
of  the  normal  rabbit,  dog  or  cat. 

Some  leucocytes  crumble  up  into  small  protoplasmic  fragments. 
They  thus  assist  in  the  formation  of  hyaline  acidophile  balls,  which 
occasionally  block  up  the  lymphatic  channels. 

Here,  mitoses  are  relatively  rare.  However,  I  have  found  some 
in  the  new-born  cat  and  in  the  grey  rat.  I  have  noticed  them 
to  be  much  more  abundant  in  the  rabbit,  into  whose  blood  I  had 
injected  pilocarpine.  In  the  rabbit,  certain  leucocytes  present 
crown-shaped  chromosomes  ;  and  it  is  not  unusual  to  observe  this 
arrangement  in  the  cords,  and  even  in  the  glandular  follicles. 


96 


THE    LYMPHATICS 


FIG.  26. — Lymphatic    passages    of     the     rnesentcric     gland 
guinea  pig  (injected  by  Gerota's  method). 


of    the 


Lymphatic  Vessels. — The  afferent  lymphatics  approach  the  convex 

portion    of    the 
gland  obliquely. 


As  they  pass 
through  the 
capsule,  they 
lose  their  ad- 
ventitious con- 
nective tissue 
muscular  coat, 
and  like  true 
capillaries,  be- 
come reduced 
to  their  enclo- 
t  helium.  The 
capillaries  form. 

by  their  anastomoses,  a  vast  peripheral  sinus,  which,  almost 
everywhere,  separates  the  capsule  from  the  follicles.  From 
this  sinus  interfollicular  branches  run  out,  which  reach  the 
central  or  medullary  part.  In  this  part,  they  run  between  the 
follicular  cords  and  finally,  throw  themselves  into  the  afferents  in 
the  region  of  the  hilum.  We  know  that  the  latter  are  lym- 
phatic trunks  which  are  less  numerous  but  larger  than  the  afferents. 
Thus,  the  portions  of  glandular  substance  properly  so  called  (i.e.,  the 
follicles  and  follicular  cords),  appear  to  us  as  islets  which  are  plunged 
in  a  vast  portal  system  which  bathes  them  on  nearly  every  side. 
By  confluence  and  capillarization,  the  lymphatics  form  a  vast  pouch 
around  the  glandular  substance  in  which  the  current  is  slackened, 
and  the  pres- 
sure lowered. 

Blood  Vessels.  -  * 

-The  gland  re- 
ceives  its  blood 
vessels,  not  only 
at  its  hilum,  but 
also  at  several  \s-. 
points  in  its  cir- 
cumference. 

The  larger  ^  \  ^ 

vessels    of     the  ^*- 

FIG.  27. — Blood  vessels  of  the  mesenteric  gland  of   the  guinea  pig 
traverse  (injected   by   Gerota's  method). 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM    97 

the  central  or  medullary  part  of  the  gland.  They  follow  the  con- 
nective tissue  arches,  and  give  off  numerous  branches  which,  by 
their  multiple  anastomoses,  constitute  a  very  rich  capillary  net- 
work. They  give  off  branches  which  run  in  the  follicular  cords, 
where  they  form  networks  with  elongated  meshes.  It  is  interest- 
ing to  observe  that  the  follicular  cords  are  pierced  in  the  centre 
by  an  arteriole  as  are  the  malpighian  corpuscles  of  the  spleen. 

The  arteries  reach  the  cortical  layer  and  surround  the  follicles,  to 
which  they  furnish  little  branches  which  converge  towards  the  centre, 
like  the  spokes  of  a  wheel  towards  the  axle.  Some  vessels  continue 
their  course  between  the  follicles  and  eventually  anastomose  with 
the  capsular  vessels.  Quite 
recently,  Calvert  has  insisted 
on  this  fact.  According  to 
this  author,  there  is  always 
an  artery  at  the  centre  of 
the  follicle,  and  the  capil- 
laries are  directed  from  the 
centre  to  the  periphery, 
where  they  join  to  form  the 
venous  radicles. 

Nerves. — In  the  large 
glands  of  man,  Koelliker 
saw  small  peri-arterial  ner- 
vous trunks  penetrating 
into  the  medullary  mass  ; 
in  the  ox,  he  observed 
Remak's  fibres  without 

being  able  to  observe  their  modes  of  termination.  Schaffner  had 
described  little  glandular  masses  in  the  course  of  these  nerves,  which, 
however,  have  not  since  been  found.  By  Golgi's  method,  Retzius 
stained  the  reticulum  and  showed  the  existence  of  perivascular 
nerve  fibres  which,  leaving  the  vessels,  terminate  by  fine  branches, 
in  the  lymphoid  tissue.  He  has  therefore  come  to  the  conclusion 
that  in  lymphatic  nodules,  as  in  the  spleen,  there  are  other  nerves 
than  vascular  nerves. 

In  figure  28,  taken  from  a  preparation  of  Manouelian,  fine 
interfollicular  plexuses  are  seen.  Some  of  the  trunks  surround  the 
follicles  and  give  off  finer  branches  which,  taking  an  oblique  course, 
reach  the  centre  of  the  nodular  structure,  where  they  appear  to 
terminate  by  free  extremities.  A  suprafollicular  and  perhaps  an 
intrafollicular  plexus  exists. 


FIG.    28.-  Nerves    of    the    mesenteric  gland  of  a 
new-born  dog  (Golgi's   method  .    From  an    un 
published  preparation  of  Manouelian). 


98 


THE    LYMPHATICS 


VARIATIONS. — The  gland,  the  most  highly  developed  and  also  the 
most  complex  of  lymphoid  organs,  presents  numerous  variations 
which  vary  in  different  regions,  in  different  species  of  animals, 
and  especially  in  different  stages  of  its  evolution. 

Regional  Variations. — These  are  relatively  of  little  importance. 
According  to  Frey,  the  medullary  portion  is  more  developed  in  the 
thoracic  and  abdominal  glands  than  in  those  of  the  axilla  or  groin. 
We  know,  however,  that  all  glands,  to  start  with,  have  a  scanty 
medulla. 

According  to  Schmorl,  the  connective  tissue  is  more  developed  in 
the  peripheral  than  in  the  visceral  glands. 

The  bronchial  are  more  vascularized  than  the  mesenteric  glands. 
In  the  rabbit,  the  mesenteric  glands  contain  in  their  medullary 

sinuses,  their 
cords,  and  even 
in  their  cortical 
layer,  masses  of 
yellowish  granules 
which  are  insol- 
uble in  alcohol  and 
chloroform,  and 
are  stained  emer- 
ald green  by  Un- 
na's  blue.  These 
granules  are  ap- 
parently not  fer- 
ruginous. They  do 
not  disappear  in 
animals  which  have  died  from  starvation. 

Owing  to  their  infiltration  by  carbon  particles,  the  bronchial  glands 
of  man  and  of  the  dog  are  black.  Particles  of  charcoal  are  deposited 
in  the  medullary  cords,  and  sometimes,  though  very  rarely,  in  the 
follicles.  They  are  grouped  in  masses  of  unequal  size  ;  and  are  often 
enclosed  within  phagocytes.  In  the  bronchial  gland  of  the  dog,  I 
have  seen  fine  ferruginous  granules  enclosed  in  the  phagocytes  of 
the  sinuses,  and  in  the  peri  vascular  cells.  Chemical  analysis 
showed  this  gland  to  contain  0'58  gr.  per  cent,  of  iron. 

Variations  in  Different  Animals. — We  know  that  the  cortical  layer 
is  more  developed  in  small  rodents  than  in  the  dog,  in  which  latter, 
on  the  contrary,  the  connective  tissue  is  more  abundant.  According  to 
Labbe,  the  cat  possesses  a  gland  which  is  very  rich  in  active  follicles. 


FIG.  29. — Bronchio-tracheal  gland  of  the  clog.     Carbon  particles. 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM  99 


FIG.  30. — Mesenteric  gland  of  the  hedgehog 


In  a  mesenteric  gland  of  the  grey  rat,  I  have  found  nucleated 
red  blood  corpuscles,  in  someAvhat  large  numbers,  both  in  the  cortical 
layer  and  in  the  sinus. 

The  gland  of  the  hedgehog  is  remarkable  for  the  scantiness  of  its 
follicular  cords,  between  which  are  seen  rounded  or  oval,  large  or 
small  meshes,  which  may  or  may  not  be  partitioned  off  by  fine 
filaments. 

In  the  follicular 
cords,  in  the  con- 
nective  tissue 
arches,  and  even 
in  some  of  the 
sinuses  I  have 
found  Ehrlich's 
cells  rounded  or 
elongated.  Some 
of  them  were  very 
small,  and  had  a 
nucleus  like  that 
of  rnicrocytes.  It 
is  known  that  it 

is  exceptional  to  find  Ehrlich's  cells  in  the  glands  of  the  rabbit  and 
guinea-pig. 

In  the  capsule,  the  cortical  layer,  and  some  of  the  medullary  cords, 
were  isolated  eosinophiles,  or  eosinophiles  in  groups  of  four  or  five. 
The  sinuses  contained  very  few  of  them.  One  eosinophile  of  the 
cortical  layer  was  in  mitosis  ;  several  showed  a  single  round 
nucleus,  as  colourable  as  that  of  the  other  leucocytes.  In  the 
follicles  of  this  gland,  macrocytes  with  basophile  granules  were 
seen. 

The  pig's  gland  is  very  simple.  A  connective  tissue  capsule, 
thick  and  quadangular  in  the  region  of  the  hilum,  but  elsewhere  thin , 
more  or  less  completely  isolates  it  from  neighbouring  glands  with 
which  it  shows  a  tendency  to  unite.  It  is  reduced  to  an  homo- 
geneous layer  which  is  precisely  similar  to  the  cortex  of  ordinary 
glands.  In  this  layer,  the  follicles  are  scattered.  Sinuses  are  seen  only 
at  the  circumference  of  the  follicles,  and  of  the  peripheral  connective 
tissue  arches.  There  are  then,  neither  follicular  cords,  nor 
cavernous  channels.  The  cells  have  a  normal  appearance.  We 
may  further  note  the  presence  of  macrocytes  with  basophile 
protoplasm  in  the  follicles.  In  the  perifollicular  layer,  a  fair  number 


100 


THE   LYMPHATICS 


Con- 
nective 

tissue 
frame- 

work 


Fio.  31. — Mescnteric  glands  of  the  pig. 


of  eosinophiles  may  be  found,  the  majority  of  which  have  a  nucleus 
which  is  identical  with  that  of  ordinary  cells,  and  there  are  some  in 

which   the    proto- 

/^  •  >>•-•--"--  ^J'.V.  :\  *.     -: 

•*:^.,r~:-^i-^:f--3':-.  :. 


plasm  contains 
three  or  four  gran- 
ules only.  In  the 
connective  tissue 
arches,  intheperi- 
f  ollicular  layer,  and 
sometimes  even, 
on  the  border  of 
the  follicle, 
Ehrlich's  cells 
may  be  seen  iso- 
lated or  massed 
together  :  there 
they  are  small  or 
large,  rounded  or 

elongated ;    the    nucleus,    which    is    usually    oval,    is    at    times 
coloured  pale  blue,  and  at  others,  a  violet  rose  by  Unna's  blue. 

I  have  examined  six  glands  from  the  pig  without  being  able  to 
find  the  least  trace  of  haematophagosis. 

Schumacher,  contrary  to  Rawitz's  experience,  has  proved  that  the 
monkey's  gland,  like  that  of  other  mammals,  has  germinatival  centres. 
Evolutionary  Variations. — Insenescence.  —  The  gland,  a  highly- 
developed  organ,  disappears  early,  without  ever  possessing  a  per- 
manent structure  to  any  great  extent.  These  incessant  variations 
result  from  the  multiplicity  of  its  functions,  especially  from  its  capa- 
bility of  performing  the  functions  of  other  organs.  We  know  how 
close  are  the  ties  which  unite  it  to  the  paradigestive  lymphoid  for- 
mations, the  spleen  and  even  to  the  bony  marrow. 

The  only  differences  are,  that,  while  the  tonsil  and  spleen  consti- 
tute sites  for  the  origin  of  the  lymphatic  vessels,  the  lymphatic 
glands,  on  the  contrary,  are  placed  in  the  course  of  the  latter.  The 
spleen  is  a  gland  interposed  in  the  course  of  the  blood  stream. 

Under  these  circumstances,  we  can  well  understand  how,  in  spite 
of  a  specialization  more  apparent  than  real,  numerous  vicarious 
functions  are  possible  which  render  the  study  of  this  organ  a  very 
complex  one :  for  instance,  after  splenectomy,  the  eosinophiles  of 
the  gland  increase  ;  and  haematophagosis,  usually  discreet  or 
insignificant,  now  assumes  larger  proportions.  Dominici  says  that 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM     101 


under  these    circumstances    the   gland    undergoes    splenoid  trans- 
formation. 

The  iron  in  the  gland  may  increase :  with  Guillemonat  I  have 
found,  in  such  cases  0'06  gr.  0'08  gr.  and  even  O'll  gr.  of  this  metal 
in  each  100  parts.  Twice,  on  the  contrary,  I  have  only  found  traces 
of  it. 

On  the  other  hand,  after  bleeding  and  exhaustion  it  seems  to 
diminish.  We  shall  see,  however, 
that  some  authors,  on  the  con- 
trary maintain  that  under  these 
conditions,  glandular  haemato- 
poiesis  is  more  active. 

In  an  animal  during  gestation, 
it  is  not  unusual  to  find  a  consider- 
able number  of  nucleated  red 
blood  cells  (Masslow).  Dominici 
describes  the  gland  of  a  preg- 
nant female  as  a  gland  which 
is  undergoing  myeloid  trans- 
formation. To  glands  which 
contain  many  Neumann's  and 
Ehrlich's  cells,  eosinophiles,  with 
a  single  nucleus,  and  polynuclears, 
Scott  Warthin  gives  the  name  of 
myelolymphatic  glands. 

Insenescence. — Atrophy  takes  place  prematurely,  seeing  that  in 
the  adult  man,  all  mitoses  may  be  observed  to  disappear,  and  sclerosis 
makes  its  appearance ;  the  latter  process  invades  the  whole  of  the 
organ  in  the  aged.  This  sclerosis  is  peripheral  and  central.  At  the 
periphery,  it  is  the  capsule  which  thickens ;  while  at  the  centre,  it  is 
the  excessive  proliferation  of  the  perivascular  arches  which  transforms 
the  medulla  into  a  fibrous  block  ;  but,  surrounded  in  this  concentric 
sclerotic  band,  there  still  remains  a  fine  band  of  cortical  substance 
which  is,  in  its  turn,  eventually  split  up  and  invaded  by  the  sclerosis 
which  makes  its  appearance  round  the  vessels  (vide  fig.  32). 

Demoor  does  not  agree  with  Orth,  His,  and  Billroth,  who 
maintain  that  as  age  advances,  the  nuclei  in  the  cells  of  the  network 
eventually  disappear  completely.  Contrary  to  Frey's  experience, 
he  did  not  observe  the  fatty  degeneration  or  pigmentary  infiltration 
of  the  cells  of  the  network.  I  looked  for  one  or  the  other  of  these 
changes  in  three  or  four  very  old  dead  subjects,  but  in  vain.  In 


FIG.  32. — Mesenteric  gland  from  an  old 
man. 


102  THE    LYMPHATICS 

these  fibrous  glands  there  are  no  longer  traces  of  macrocytes 
(macrophages)  in  the  sinuses. 

FUNCTIONS.  — Leucocytocjenesis.  —  Whether  glandular  cells  are  fixed 
leucocytes  or  autochtonous  derivatives  of  mesodermic  elements,  at 
any  rate  they  produce  the  white  corpuscles.  In  fact,  the  latter  are 
more  numerous  in  the  efferent  than  in  the  afferent  vessels  ;  there  is 
a  close  relation  between  blood  leucocytosis,  glandular  hypertrophies, 
and  the  number  of  mitoses.  Similarly,  the  experimental  removal  of 
certain  important  glandular  groups  produces  hypoleucocytosis. 

The  glandular  cells  are  therefore  clearly  lymphogenous,  and  the 
gland  is  a  cytogenous  gland  like  the  testicle.  In  this  connexion,  it  is 
interesting  to  recall  the  fact  that  these  two  mesodermic  organs  which 
are  so  distinct  in  vertebrates,  are  blended  in  certain  invertebrates, 
viz.  the  lympho-sexual  glands  of  the  Bryozoae,  and  of  some  of  the 
Polychetae  (Cuenot). 

The  gland  specially  produces  microcytes  (lymphocytes),  and  very 
probably,  macrocytes  (large  mononuclears)  also.  The  microcytes, 
numerous  in  the  gland  and  in  the  efferent  channels,  increase  in 
pathological  or  experimental  (splenectomy)  glandular  hypertro- 
phies. 

On  the  other  hand,  they  diminish  after  extensive  glandular 
ablations  (Rokitzki,  Tchigaieff,  Ehrlich  and  Reinbach),  and  after 
ligature  of  the  thoracic  duct  (Koroboff). 

There,  eosinophiles  are  again  formed  and  perhaps  also,  sometimes, 
cells  with  neutrophile  granules.  The  eosinophiles,  which  are  often 
numerous,  rarely  present  mitoses  :  Jolly  has  seen  one  in  the  rabbit  ; 
I  have  seen  one  in  the  hedgehog  :  it  is  the  eosinophiles  with  a  single 
round  nucleus  which  are  more  frequently  observed  in  the  gland  or  in 
the  lymphoid  portion  of  the  thymus;  Labbe  notes  the  existence  of  simi- 
lar cells  in  the  guinea-pig,  and  I  have  found  them  in  the  rabbit,  pig  and 
hedgehog.  Further,  there  are  some  eosinophiles  with  few  granules, 
whose  nucleus,  in  its  shape,  staining  properties,  and  arrangement  of 
its  chromatin,  resembles  at  times  microcytes,  and  at  others,  ordinary 
macrocytes.  It  would  seem  as  though  we  were  witnessing  the  first 
appearance  of  granules  and  their  progressive  development  in  a  cell 
which  was  at  first  destitute  of  them.  We  should  also  note  the  presence 
of  the  blood  eosinophile  which  accompanies  certain  glandular  hyper- 
trophies (lymphadenoma,  splenectomy).  It  is  therefore  almost  certain 
that,  following  the  opinion  of  Hoyer,  Schaffer,  and  more  recently  of 
Labbe,  there  is  sometimes,  if  not  always,  a  production  of  eosinophiles 
in  the  lymphoid  tissues  (gland  and  thymus).  In  the  normal  frog^ 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM    103 

eosinophiles  are  produced  in  the  spleen.  It  has  long  been  known 
that  the  gland  encloses  multinucleated  cells,  and  cells  with  a 
polymorphous  nucleus;  but  the  polymorphism  of  the  nuclsus  does 
not  necessarily  imply  the  presence  of  neutrophile  granules.  Quite 
recently,  Dominici  has  seen  cells  with  neutrophile  granules  develop 
in  lymphoid  tissue.  This  is  the  natural  and  almost  necessary 
consequence  of  the  presence  in  the  tissue  of  basophile  macrocytes 
analogous  to  myelocytes. 

Haematopoiesis. — Now  to  complete  its  resemblance  to  the  bony 
marrow  and  the  embryonic  spleen,  we  may  inquire  if  the  gland 
is,  or  at  any  rate  can  under  any  circumstances  become,  a  centre 
of  haematopoiesis  ? 

The  possibility  of  its  acting  as  a  substitute  in  this  way  seems 
demonstrated  by  a  very  suggestive  observation  of  Rindfleisch. 
This  pathological  anatomist  found  Neumann's  cells  in  the  hyper- 
trophied  glands  of  a  rachitic  infant,  in  whom  the  bony  marrow 
was  absent. 

Saxer  attributes  this  function  to  the  embryonic  gland,  and 
Retterer  regards  it  as  a  fundamental  property  of  adult  lymphoid 
tissue.  According  to  this  histologist,  the  glandular  cells  elaborate  red 
b'ood  cells,  either  by  means  of  their  nucleus,  or  of  their  protoplasm  : 
the  "haemoglobic  degeneration"  of  the  nucleus  gives  rise  to  red 
discoid  blood  globules,  while  that  of  the  protoplasm,  which  is  less 
common,  produces  red  nucleated  corpuscles. 

There  are  certain  glandular  cells,  the  nucleus  of  which  when  in  a 
state  of  degeneration,  stains  with  cosine  or  orange,  and  which  in 
shape  very  closely  resembles  red  corpuscles.  Is  this  sufficient  to  prove 
that  these  elements  are  red  corpuscles  in  process  of  formation  ? 
We  may  at  least  have  our  doubts  on  this  point.  The  lymphoid 
tissue  and  the  sinus  may,  however,  contain  red  blood  cells,  which 
are  sometimes  nucleated.  As  regards  the  pathological  con- 
dition, when  there  are  congestions,  or  visceral  haemorrhages, 
when  the  blood  carries  away  Neumann's  cells,  this  state- 
ment furnishes  no  decisive  argument  in  favour  of  glandular 
haematopoiesis.  Under  these  circumstances,  it  is,  in  fact, 
impossible  to  prove  that  the  red  blood  cells  found  in  the  gland 
have  originated  there,  and  have  not  arrived  there  through 
diapedesis  (Schumacher),  or  through  a  vascular  rupture  (Saltikow). 
On  the  other  hand,  we  cannot  assume  a  similar  origin  for  the  cells 
of  Neumann  which,  while  absent  in  the  normal  blood  of  adults,  are 
sometimes  present  in  the  cortical  layer  and  in  the  cavernous  passages 


104  THE   LYMPHATICS 

of  the  gland.  I  observed  this  fact  in  the  grey  rat  and  in  the  pig  : 
in  the  rat,  we  have  to  deal  with  giant  nucleated  red  blood  cells 
almost  entirely,  whose  protoplasm  is  unequally  rich  in  haemoglobin. 
Some  possess  a  nucleus,  in  which  a  reticulum  and  chromatin 
nucleoli  can  be  distinguished  ;  others  have  a  smaller  nucleus 
deeply  and  diffusely  stained  ;  finally  there  are  some  in  which  the 
nucleus  is  very  pale,  poor  in  chromatin,  and  seems  to  be  in 
process  of  disappearing.  In  the  pig,  the  nucleated  red  blood  cells, 
which  are  usually  small,  are  transformed  into  ordinary  red  blood 
corpuscles  by  nuclear  excretion. 

Glandular  haematopoiesis,  though  it  sometimes  undoubtedly  takes 
place,  seems  very  inconstant,  or  atany  rate  very  intermittent :  histolo- 
gical  examination  by  no  means  always  demonstrates  the  constant 
presence  of  Neumann's  cells  in  glandular  tissue  :  moreover,  chemical 
analysis  agrees  with  histology  in  proving  this  inconstancy.  In  glands 
taken  from  the  slaughter  house,  Schmidt  found  no  haemoglobin.  In 
six  out  of  fourteen  examinations,  we,  agreeing  with  Guillemonat, 
found  only  inappreciable  traces  of  iron  (three  times  an  infinitesimal 
amount,  and  three  times  larger  traces).1 

Haematolysis  and  Phagocytosis.  —  In  the  pathological  state 
owing  to  the  presence  of  its  macrocytes  (rnacrophages  of  Metch- 
nikoff),  the  gland  may  become  an  active  centre  of  haematophagasis 
and  consequently  of  haematolysis. 

In  intoxications  caused  by  phosphorus  and  arsenic,  and  in 
poisoning  by  toluilin-diamin,  Hover  observed  numerous  examples 
of  glandular  haematophagasis,  and  though  Retterer  denies  this 
function,  Gabbi,  Schumacher,  and  Thome  regard  it  as  a  constant 
function  of  the  healthy  gland.  Scott  Warthin  localizes  this  function 
in  certain  glands,  or  rather  in  certain  haemolymphatic  or  splenoidal 
glands,  which  have  been  studied  by  Leydig,  Gibbes,  Robertson, 
Clarkson,  Sisto  and  Morandi,  Morandi  and  Piato. 

It  is  quite  clear  that  if  haematophagasis  were  present  to  any  great 
extent  in  all  normal  glands  the  latter  would  be  red  and  would 
always  contain  iron  in  fairly  large  proportion  ;  we  know,  however, 
that  such  is  not  the  case. 

Moreover,  we   do   not  always   see   the   histological   signs  of  an 

1  The  estimations  were  carried  out  by  Lapicque's  method.  The  animals 
(pig,  dog,  rabbit,  rat)  were  killed  by  bleeding,  and  the  glands  washed  in  dis- 
tilled water.  We  have  thus  as  far  as  possible  avoided  the  cause  of  error 
due  to  the  presence  of  blood;  this  cause  of  error  is  more  easily  elim- 
inated in  the  case  of  the  gland  than  in  that  of  the  spleen. 


GENERAL  ANATOMY  OF  THE   LYMPHATIC  SYSTEM    105 

extensive  glandular  haemolysis  in  the  normal  state.  This  process, 
which  is  often  absent  or  insignificant,  has  not  appeared  to  me  so 
marked  as  it  is  in  the  mesenteric  glands  of  the  rabbit  after 
splenectomy,  or  after  the  injection  of  pilocarpine. 

Even  after  splenectomy,  it  is  inconstant  or  transitory.  At  various 
times  after  this  operation  I  have  examined  the  mesenteric 
glands  of  eight  rabbits,  without  ever  observing  (contrary  to  the 
experience  of  Lockart  Gibson  and  Moses  Griinberg),  the  slightest 
redness  or  the  least  macroscopic  hypertrophy.  The  increase  in 
the  amount  of  iron  is  also  inconstant.  Though,  on  three  occasions, 
0*06  gr.,  0'08  gr.,  and  O'll  in  each  1000  parts  were  found,  on  two 
occasions,  there  were  only  traces. 

We  can  understand  how  the  same  organ  exercises  these  two 
antagonistic  functions  of  haematolysis  and  haematopoiesis  simul- 
taneously or  intermittently,  seeing  that  the  former  furnishes  the 
materials  for  the  latter  process. 

Owing  to  its  slow  circulation  and  to  its  innumerable  phagocytes, 
the  gland  is  also  a  place  where  inert  or  living  particles  brought  to 
it  by  the  afferents  are  arrested.  We  are  acquainted  with  the 
carbon  infiltration  of  bronchial  glands,  and  the  yellowish  green 
pigmentation  of  the  mesenteric  glands  of  the  rabbit.  Schmorl 
found  that  glands  draining  a  pigmented  or  tattoed  cutaneous  area 
were  blackish  in  colour. 

The  question  of  the  presence  of  bacteria  in  the  normal  gland 
opens  a  wider  field  for  discussion.  Wissokowitch,  Xeisser  and  Labbe 
found  the  glands  sterile  ;  Loomis,  Pizzini,  and  Kossel  were  able  by 
inoculation  to  demonstrate  the  septic  properties  of  some  of  them. 
Perey  found  in  them  both  saprophytic  and  pathogenic  agents ; 
while  Desourbry  and  Porcher,  and  Josue  found  microbes  in  the 
thoracic  duct. 

In  the  closed  follicles  of  the  appendix  of  the  rabbit  I  have  found, 
as  Denys  has,  bacilli,  even  though  the  mucus  membrane  was  his- 
tologically  intact,  and  I  have  found  the  same  thing  in  the  pig's 
gland.  The  normal  gland  may  then  contain  germs,  and  it  is  possible 
that  these  germs  may  not  be  entirely  disconnected  with  the  produc- 
tion of  the  numerous  soluble  ferments  which  are  now  being  studied. 

Amorphous  Secretions.— Rossbach  observed  the  presence  of  an 
amylase  in  the  tonsil.  Foa  and  Pellacani  produced  coagulation  of 
the  blood  by  the  intravascular  injection  of  glandular  extracts  ; 
the  lymphatic  glands  apparently  contain  thrombase.  The  difference 
in  the  amount  of  fat  contained  in  the  afferent  and  efferent  chyle 

H 


106  THE    LYMPHATICS 

had  long  been  observed  ;  quite  recently,  Poulain  found  in  the  gland 
the  lipase,  the  existence  of  which  was  known  in  the  thymus.  The 
recent  researches  of  Arthus  and  Doyon  however,  take  away  all 
interest  in  this  statement. 

Delezenne  has  discovered  in  the  mesenteric  glands  of  the  dog,  the 
pig,  and  the  rabbit  an  "  enterokynase  " — a  ferment  which  aids  the 
trypsin,  and  which  exists  also  in  Fever's  patches. 

Metchnikoff  notes  the  presence  of  a  "  fixer  "  in  the  mesenteric 
glands.  Taressewitch  states  that,  in  a  glandular  extract,  the  red 
blood  corpuscles  are  nearly  always  dissolved  :  this  is  not  the  case 
in  the  marrow  of  bone  ;  he  attributes  this  action  to  the  presence  of 
a  ferment  (?) — the  macrocytase. 

Whatever  the  truth  may  be  as  to  the  real  nature  of  this 
macrocytase,  the  gland  contains  ferments,  the  exact  origin  of 
which  we  have  still  to  learn. 

On  the  other  hand,  the  gland  is  an  important  centre  for  cytolysis  : 
its  cells  degenerate,  become  vacuolated,  and  shed  their  nuclei ;  the 
eosinophiles,  the  cells  of  Ehrlich,  there  heap  up  their  granules  : 
regarded  from  these  two  points  of  view,  it  behaves  like  a  secreting 
gland,  that  is  to  say,  like  an  organ  which,  by  a  partial  or  total 
destruction  of  some  of  its  elements,  sets  free  into  the  circulation 
a  product  which  is  useful  for  the  needs  of  the  organism. 

According  to  Asher,  the  products  of  katabolism  provoke  the 
glandular  functions,  and  the  result  of  this  is  the  transformation  of 
the  waste  products  of  cellular  life. 

In  fact,  the  lymph,  which  is  a  product  of  organic  work  and 
therefore  charged  with  poisons,  is  not  eliminated  externally : 
thrown  into  the  general  circulation,  as  it  is,  it  can  only  undergo 
modification  in  the  gland  and  lung. 

On  the  other  hand,  the  presence  of  an  amylase,  and  of  enteroky- 
nase seem  to  indicate  that  the  gland  which  is  capable  of  digesting 
certain  bacteria,  is  also  capable  of  digesting  certain  chemical 
substances. 

According  to  the  splendid  conception  of  MetchnikofT,  the  actions 
of  defence  against  microbic  invasion,  and  the  actions  of  an  intimate 
nutrition  are  united  in  the  same  gland.  These  functions  of  the 
closed  gland  which  can  modify  its  contents,  but  about  which  we  are 
still  very  ignorant,  complete  the  analogy  which  it  presents  to  other 
mesodermic  and  cytogenous  glands  such  as  the  testicle  and  ovarv. 

BIBLIOGRAPHY. — Sylvius.  Disput.  anat.,  V  et  VI. — Wharton.  Adeno- 
graphia,  sive  glandularum  totius,  carports  descriptio,  1664. — Nuck.  Adeno- 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM  107 

graphia  curiosa  et  uteri  jemincei  anat,  nova,  1691. — Malpighi.  Marcelli  Malpighi 
de  structura  glandularum  conglobatarum  consimiliumque  partium  epistolce, 
1697. — de  Graaf.  Opera  omnia,  1765. — Cruikshanks.  The  anatomy  of  the 
absorbing  vessels  of  the  human  body,  1786. — Hewson.  The  works  of  William 
Hewson,  18-16. — Mayer.  Salzb.  med.  ch.  Zeitung,  1815,  IX. — Neumann.  Von 
der  Natur  des  Menschen,  1815. — Bichat.  Anatomie  generate,  1818,  II. — 
Chaussier  et  Adelon.  Art.  "  Lymphatique."  Diet.  Sciences  medic.,  1818. — 
Lauth.  Th.  Strasbourg,  1824. — Breschet.  Le  systeme  lymph.  Paris,  1836. — 
Bonders.  Physiologic,  iibersetzt  von  Theile,  Bd  I. — Herbst.  Das  Lymphyc- 
fdsssysiem  u.  seine  Verrichtung.  Gottingen,  1844. — Noll.  U.  den  Lymphstroni. 
Zeitschr.  f.  rat.  Medicin.,  1850. — Engel.  Bau  u.  Entwickelung  der  Lymph- 
driisen.  Prager  Vierteljahrschrift  fur  prakt.  Heilkunde,  1850,  XXVI. — Heyd- 
felder.  U.  den  Bau  der  Lymphdriisen.  Inaug.  Diss.  Erlangen,-  1851. — Gerlach. 
Gciz.  hebd.  med.,  1856,  III. — Brucke.  U.  die  Chylusgefasse  u.  die  Fortbewe- 
gung  der  Chylus.  A  cad.  Sciences,  Vienne,  1853,  IV  et  X. — Leydig.  Lehrbuch 
dsr  Histologie,  1857. — Billroth.  Mutter's  Archiv,  1857  ; — Beitrdge  zur  path. 
Histologie.  Berlin,  1858. — Eckard.  De  glandul.  lymphat.  structura.  Diss. 
Inaug.  Berlin,  1858. — Henle.  Zeitschrift  f.  ration.  Medicin,  1860,  3  serie. 
vol.  VIII. — His.  Unters.  iiber  den  Bau  der  Lymphdr.,  Leipzig,  1861. — Frey, 
Unters.  iiber  die  Lymphdr.  der  Menschen  u.  der  Sdugethiere,  Leipzig,  1861. — 
His.  Zeitschrift  f.  wissenschaftl.  Zoologie,  1862,  XXI. — Billroth.  Zur  Structur 
der  Lymphdriisen.  Zeitschr.  f.  wissenschaftt.  Zoologie,  1861-1862,  XI. — 
Schmidt.  Das  folliculare  Driisengewebe  der  Schleimhaut  der  Miindholile. 
Zeitschrift  wiss.  Zool.,  1863,  XIII. — Labedat.  Systeme  lymphat.  These  agreg., 
1866. — Sertoli.  Entwick.  d.  Lymphdriisen.  Sitzungsber.  d.  Wiener  Akad., 
1866. — Crocq.  Gazette  des  hopitaux,  1868. — Orth.  Unt.  iiber  Lymphdrusenent- 
wickelung.  Inaug.  Diss.,  Bonn,  1870. — Bizzozero.  Sulla  struttura  delle 
ghiandole  linfatiche.  Rendi  conti  reale  institute  lombardo.  Serie  II,  vol.  V, 
fasc.  2.  Gennazo,  1872. — Klein.  The  anatomy  of  the  lymph,  system:  The 
serous  membranes.  London,  1873. — Ducastel.  Anatomie  normale  et  patho- 
logique  des  ganglions  lymphatiques.  Soc.  Anat.,  1874. — Kupffer.  Ueber 
die  Sternzellen  der  Leber.  Arch.  f.  mikrosk.  Anat.,  1876,  XII. — Bizzozero. 
Beitrage  zur  Kentniss  des  Baues  der  Lymphdriisen.  Moleschotfs  Unter 
siichungcn  zur  Naturlehrc,  1876,  II. — Pouchet.  Note  sur  la  structure  des 
ganglions  lymphatiques.  Gaz.  med.  Paris,  1879. — Arnold.  Karyokineses 
dans  les  ganglions  hypertrophies.  Virchow's  Arch.,  1879. — Rindfleisch.  U. 
Knochenmark  u.  Blutbildung.  Arch.  f.  mikr.  Anat.,  1879,  XVTI. — Garel. 
Recherches  sur  1'anatomie  generale  comparee  et  la  signification  morpho- 
logique  des  glandes  de  la  muqueuse  intestinale  et  gastrique  des  animaux 
vertebres.  These  Lyon,  1879,  lre  serie,  n°  8. — Weigert.  Virchow's  Archiv. t 
LXXIX. — Chiewitz.  Zur  Anatomie  einiger  Lymphdriisen.  Arch.  f.  Anat. 
u.  Entwick.,  Anat.,  Abth,  1881. — Neumann.  U.  Blutregeneration  u.  Blut- 
bildung. Zeitschr.  /.  klin.  Med.,  1881,  III. — Winogradow.  Centmlbl.  f.  div 
med.  Wissenschctft.,  1882,  n°  50. — Foa  et  Pellacani.  Sur  le  ferment  fibrinogene 
et  sur  les  actions  toxiques  exercees  par  quelques  organes  frais.  Arch.  Ital. 
de  biol,  1883,  IV,  p.  I.— Masoin.  Acad.  med.  Belg.,  1880,  XIV,  n°  11.— 
Kultschitzky.  Die  Enstehung  der  rothen  Blutkorp.  bei  den  Saugethieren. 
Arbeiten  der  Naturforschergesellschaft  in  Charkoiv,  XV. — Einhorn.  Ueber 
das  Verhalten  der  Lymphocyten.  Inaug.  Diss.  Berlin,  1884. — Drews.  Zellver- 
mehrung  in  der  Tonsilla  beim  Erwachsenen.  Arch.  f.  mikr.  Anat.,  1884,  XXIV. 
—Arnold.  Vir chow's  Archiv,  1882,  LXXXVII  ;  1884,  XCV.— Toldt.  Lehrbuch 
der  Gewebelehre,  2e  ed.,  1884. — Stohr.  Ueber  Mandeln  u.  Balgdriisen.  Virchow's 
Archiv,  1884,  XCVII. — Gibbes.  Microscopical  Journ.,  1884,  XXIV; — Amer. 


108  THE    LYMPHATICS 

Journ.    of    med.    Sciences,    1893. — Flemniing.    Die    Zellvermehrung    in    den 
Lymphclriisen.   Arch.   /.   mikr.   Anat.,    1885,    XXIV,    p.     50. — Baumgarten. 
Zeit.  /.   klin    Med.,    1885,   IX  et  X. — Paulsen.   Zellvermehrung  in  Ivyperpl. 
Lymphdnisen.  Arch.  f.  mikr.  Anat.,  1885,  XXIV. — W.  His.  Anat.  menschlich. 
Embryonem:     III.   Zur  Geschichte  der   Organen,   Leipzig,    1885. — Retterer. 
Contrib.  a  1'  etude  du  cloaque  et  de  la  bourse  de  Fabricius  chez  les  oiseaux. 
Journ.  Anat.  et  Phys.,   1885  ; — Sur  le  developpement  des  tonsilles  chez  les 
mammiferes.    C.    R.    Acad.    Sciences,    14   dec.    1885. — Lockart   Gibson,    The 
blood  forming  organs  and  blood  formation.  Journ.  for  Anatomy  and  PhysioL, 
1886.  XX. — Ayoama.    Virchow's  Archiv,   1886,  CVI. — Henle.  Zur  Anat.  der 
geschlossenen  Driisen  u.  der  Lymphdriisen.  Zeits  f.  rat.  Med.,  VIII. — Suss- 
dorf.  Lymphdriisen.  Ellenberger' s  Handbuch  der  Histol.  der  Haussaiigethicrc, 
1887.— Hofmeister.  Arch.  f.  exp.  Path.  u.  Pharm.,  1887,  XXII.— Orth.  Cursus 
der    normcden    Histologie,      1888. — Davidoff.     Untersuchungen     ueber     die 
Beziehungen     des    Darmepithels    zum    lymphoi'den     Gewebe.       Arch.      f. 
mikr.      Anat.,     1887,       XXIX. — Mall.      Reticulated     and     yellow      elastic 
tissues.  Anat.  Anzeig.,  1888  ; — Das  reticulierte  Gewebe  u.  seine  Beziehungen 
zu  den  Bindegewebsfibrillen.   Abhandl.   math.  phys.   Sachs.   Gesellsch.    Wiss., 
1891,  XVII.— Sanfelice.  Boll,  della  Soc.  di  natur.  in  Napoli,  1889.— Stohr.U. 
die  Lymphknotchen  cles  Darmes.   Arch.  /.   mikr.   Anat.,    1889,  XXXIII. — 
Kourloff.  Wratch,  1889,  p.  515  ;    1892,  p.  469. — Hoyer.  Beit-rag  zur  Kentniss 
der  Lymphdriisen.  Arch.  f.  mikr.  Anat.,  1889,  XXXIV. — Ribbert.  Regenera- 
tion u.  Entziindung  der  Lymphdrii  sen.  Ziegler'sBeitrage,  1889,  VI. — Kceppe. 
Arch.  f.    Phys.  Supplement  Heft,    1890. — Laguesse.  Recherches   sur   le    de- 
veloppement de  la  rate  chez  les  poissons.    Th.   Doct.   es  sciences  : — Journ. 
Anat.   et  Phys.,    1890.— Robertson.   Lancet,    1890.— Conil.   Devel.   du    gangl. 
lymphat.  These  Bordeaux,  1890. — Closes  Crunberg.  Experiment elle  Untersu- 
chungen  ii.    die   Regeneration   der   Blutkorperchen   in   den   Lymphknoten. 
These   Dorpat,    1890. — Lowit.       Wiener   Sitzungsberichte,     1883-1885-1887  ; 
—Die    Anordnung     d.      Leukoblasten     u.    Erythroblasten.     in    den    Blut- 
zellenbildenden     Organen.     Anat.    Anzeiger,     1891,     p.     344  ;      — Arch.    f. 
mikr.   Anat.,  XXXVIII. — Retterer.    Origine  et  developpement  del  plaques 
de  Peyer    chez    le  lapin  et  le  cobaye.    C.   R.   Soc.   Biol.,   24  dec.     1891. — 
Zacharow.  Zur  Frage  iiber  die  Verand.  der  Lymphdr.  im  Greisenalter.  Th. 
Peter -sb.,  1891. — Rudinger.  U.  die  Umbildung  der   Lieberkiihn'schen   Driisen 
durch  die  Follikel  im  Wurmfortsatze  des  Menschens.    Verhand.   der  Anat. 
Ges.  in  Munchen,  1891. — Stohr.  Die  Entwickelung  des  adenoiden  Geweb.  der 
Zungenbalge  u.  der  Mandeln  der  Menschen.  Festchrift  f.  Ndgeli  u.  Kollikcr. 
Zurich,  1891  ; — Anat.  Anzeiger,  1891. — Gulland.  The  development  of  adenoid 
tissue.  Reports  from  laboratory  of  the  royal  college  of  Physicians.  Edimburg, 
1891. — Oppel.  U.  Gitterfasern  cler  menschlichen  Leber  u.  Milz.  Anat.  Anzeiger, 
1891,    VI,    p.    165. — Bonnet.    Grundriss   der   Entwick.    der   Haussdugethiere, 
1891,  p.    173.— Bizzozero.  Atti  R.  Accad.  Scienze  Torino,    1892,  XXVII.— 
Ascoli.  Arch.  f.  mikr.  Anat.,  LIII. — Muller.  Zur  Kentniss  der  Bauesgesunder 
u.  Krankhaft  veranderter  Lymphdriisen.  Zeitschr.  f.  rat.  Med.,  XX,  1  et  2. — 
vStiles.  The  surg.  anat.  of  the  breast  a.  axillary  lymph,  glands.   Edim.  med. 
Journ.,   1892. — Schmidt.  Zur  Blutlehre.  Leipzig,   1892. — Gabbi.  U.  die  nor- 
male    Hamatolyse    mit   besonderer    Beriichtigung    der    Hamatolj'se  in    der 
Milz.  Ziegler's  Beitrdge.,   1893,  XIV. — Demoor.  Recherches  sur  la  structure 
du  tissu  reticule.  Arch.  Biol.,    1893,  XIX,  fasc.   3,  p.   575. — v.   d.    Stricht. 
Xature  et  division  mitosique  des  globules  blancs  des  mammiferes.  Verhand- 
lungen  der  anat.  Gesellschaft,  1893. — Retzius.  Biol.  Untersuchung.,  V,  1893. — 
Boddaert.  De  Tcedeme  d'origine  lymphatique.   Arch.  Phys.  norm,  et  path., 


GENERAL  ANATOMY  OF  THE  LYMPHATIC  SYSTEM  109 

1894,  p.  492. — Gulland.  The  developpt  of  lymphat.  glands.  Journ.  of  pathol. 
and  bact.  Edimb.,  1894. — Kanter.  Centralblatt  f.  allgem.  Pathol.,  1894,  V. — 
W.  His.  Die  anatomische  Nomenclatur.  Arch.  f.  Anat.  u.  Phys.,  Suppl.  Band, 
1895. — Rawitz.  U.  die  Zellen  in  den  Lymphdriisen  der  Macacus  cynomo- 
logiis.  Arch.  f.  mikr.  Anat.,  1895,  XLV. — Ranvier.  Structure  des  ganglions 
mesenteriques  du  pore.  C.  R.  Acad.  Sciences,  1895,  CXXI,  n°  23,  p.  800  ; — 
C.  R.  Soc.  BioL,  1895,  p.  774. — Tchigaieff.  Role  des  ganglions  lymphat iques 
dans  1' organisms  du  chien.  Th.  Petersbourg,  1895. — Saxer.  U.  Entwickelung 
u.  Bau  der  normaleii  Lymphdriisen.  Anat.  Hefte,  1896,  VI,  p.  349. — Ranvier. 
Dev.  des  ganglions  lymphatiques.  C.  R.  Acad.  Sciences,  14  dec.  1896. — 
Retterer.  Dev.  des  tissus  conjonctifs  muqueux  et  reticule.  C.  R.  Soc.  BioL, 
1896,  n°  1,  p.  47. — Cantacuzene.  Appareils  et  fonctions  phagocy taires.  Annee 
BioL,  1896. — Retterer.  Origine  des  follicules  clos  du  tube  digestif.  VerliandL 
der  anat.  Gesellschaft  auf  der  neunten  Versammlung  in  Basel,  1896. — Naville. 
Dev.  des  follicules  clos  dans  la  conjonctive  oculaire.  C.  R.  Soc.  BioL,  1896. 
11°  15,  p.  451. — Benda.  Ueber  den  Bau  cler  blutbildenden  Organen  u.  die  Re, 
generation  der  Blutelemente  beim  Menschen.  Physiol.  Gesellsch.  Berlin- 
feb.  1896  ; — Deut.  Med.  Woch.,  1896,  V,  p.  41. — Clarkson.  British  med.  Journ., 
25  July  1891  ; — Textbook  of  histoL,  1895. — Prenant.  Sur  la  presence  d'amas, 
leucocytaires  clans  1' epithelium  pharyngien  d'anguis  fragilis.  Bibl.  Anat., 
1896,  n°  1. — Schedel.  In  Flemming's  Studien  il.  Regeneration  der  Gewebe. 
Vergl.,  11°  3. — Disse.  Anatomic  des  Rachens.  Heymann.  Handbuch  der 
Laryngologie,  1896,  III. — Evvald  u.  Kuhne.  Verhandlungen  der  naturhist. 
med.  Vereines  zu  Heidelberg,  I,  5. — Hcehl.  Zur  Histologie  der  adenoi'den 
Ge webes.  Arch.  f.Anat.  u.  Phys.,  1897,  fasc.  I  et  II,  p.  133.— Schumacher.  U. 
die  Lymphdriisen  der  Macacus  Rhesus.  Arch.  f.  Mikr.  Anat.,  1898,  XL VIII  ; 
1899,  LIV.— Retterer.  Journ.  de  I' Anat.  et  de  la  Phys.,  1897,  p.  463  ;— Origine 
6pitheliale  des  leucocytes  et  de  la  charpente  reticulee  des  follicules  clos. 
C.  R.  Soc.  BioL,  20  mars  1897. — Cuenot.  Les  globules  sanguins  et  lesorganes 
lymphoi'des  des  invertebres.  Arch.  $  Anat.  microscopique,  1897. — Ceresole. 
Ziejhr's  Beitr.  z.  path.  Anat.,  XVII,  p.  602. — Vincent  et  Harrisson.  Journ.  of 
Anat.  and  Phys.,  1897. — Jonnesco.  Congres  de  Moscou,  aout  1897. — Disse.  Das 
retikulare  Bindegewebe.  Ergebnisse  der  Anatomie  u.  Entwicklungsgeschichte 
Merkel  u.  Bonnet,  1897,  VII. — Masslow.  Einigc  Bemerkungen  zur  Morpho- 
logic u.  Entwickelung  der  Blutelemente.  Arch.  f.  mikr.  Anat.,  1897,  LI. — 
M.  Labbe.  fttude  du  ganglion  lymphatique  dans  les  infections  aigues.  Th. 
Paris,  1898  — Stb'hr.  U.  die  Entwickelung  der  Darmlymphkndtchen.  Arch, 
f.  mikrosk.  Anat.,  1898,  LI. — Thome.  Endothelien  als  Phagocy  ten.  Arch. 
/.  mikr.  Anat.,  1898,  LII. — Bezangon  et  Labbe.  Le  ganglion  lymphatique 
normal.  Presse  med.,  15  fevrier  1899. — Melnikow  Raswedenkow.  Histologische 
Untersuchungen  iiber  das  elastische  Gewebe.  Ziegler'sBeitrdge,  1899,  XXVI, 
p.  540. — Retterer.  Histogenese  de  1'epiploon.  C.  R.  Soc.  BioL,  1899,  p.  614.— 
Dominici.  Hots  perivasculaires  chez  le  fcetus.  C.  R.  Soc.  BioL,  1879,  p.  72.— 
Lefas.  Amas  lymphoi'des  dans  la  glande  sous-maxillaire  de  Fhomme.  C.  R 
Soc.  BioL,  1899,  p.  903. — Letulle.  Les  ganglions  parietaux  de  I'estomac. 
Bull.  Soc.  Anat.,  29  dec.  1899.— Creigh ton.  A  system  of  perivascular  lym- 
phatic cylinders  and  capsules  in  the  united  amnion  allantoi's  of  the  chick. 
Journ.  Anat.  Phys.,  1899,  XXXIII,  N.  S.  ;  XIII,  S.  527.— Saltikow  U. 
bluthaltige  Lymphdriisen  beim  Menschen.  Zeitschrift  f  Heilkunde,  1900. 
Drummond.  Journ.  of  Anat.  and  PhysioL,  1900. — Dominici.  Considerations, 
generales  sur  la  structure  des  appareils  hematopoietiques  chez  le  lapin. 
C.  R.  Soc.  BioL,  6  Janvier  1900. — SistioetMorandi.  Contribute  allo  studio  del 
reticolo  delle  linfoglandule.  Atti  d.  R.  Accad.  d.  Sc.  di  Torino,  1900,  XXXVI. 


110  THE    LYMPHATICS 

— Retterer.  C.  R.  Soc.  Biol,  mars,  avril,  mai,  juin  1900  ; — XII P  Congres 
international  de  Medecine.  Paris,  1900  ;  (C.  JR.  Sect,  d'histologie,  p.  96)  ; 
Kecherches  experiment  ales  sur  I'elaboration  d'hematies  par  les  ganglions 
lymphatiques,  Janvier  1901  ; — De  1'origine  et  de  1'evolution  des  hematies 
et  des  leucocytes  des  ganglions  lymphatiques.  C.  R.  Soc.  Biol.,  13  juillet 
1901. — Dominici.  Sur  1'histologie  de  la  rate  a  1'etat  normal  et  pathologique. 
Arch  de  Mid.  exp.,  Janvier  1901,  11°  1  ; — Sur  la  reaction  my&oide.  Presse 
medicate,  2  mars  1901. — Toukoff.  Die  Blutgefasse  der  Lymphdriisen.  Intern. 
Monatssclir.  f.  Anat.  u.  Phys.,  XV,  9,  p.  269. — Ribbert.  Beitrage  zur  Kentniss 
der  Rabclomyome.  Virchow's  Arcliiv,  CXXX,  p.  270. — de  Bruyne.  Contrib. 
a  1' etude  de  1'union  intime  des  fibres  muscul.  lisses.  Arch.  Biol.,  XII,  p.  345. 
— Haberer.  Arch.  f.  Anat.  u.  Phys.,  mars  1901. — Weidenreich.  Arch.  f.  mikr. 
Anat.,  juillet  1901. — Poulain.  Sur  la  lipase  des  ganglions  lymphatiques  a 
1'etat  normal  et  path.  C.  R.  Soc.  Biol.,  15  juin,  17  juillet  1901. — Retterer. 
Des  conditions  experimentales  qui  modifient  la  forme  et  la  valeur  des  hematies 
elaborees  par  les  ganglions  lymphatiques.  C.  R.  Soc.  Biol.,  13  juillet  1901. — 
Beard.  The  source  of  leucocytes  and  the  true  function  of  the  thymus.  Anat. 
Anzeiger,  XVIII,  nos  22,  23,  24. — Delamare.  Note  sur  les  cellules  eosinophiles 
et  les  hematies  nucleees  du  ganglion  lymphatique  normal.  C.  JR.  Soc.  Biol., 
5  octobre  1901. — Guillemonat  et  Delamare.  Le  fer  du  ganglion  lymphatique. 
C.  R.  Soc.  Biol.,  26  octobre  1901. — Retterer.  Structure,  developpement  et 
fonctions  des  ganglions  lymphatiques.  Journal  de  Vanatomie  et  de  la  physiologie, 
1901,  nos  5  et  6. — Scott  Warthin.  The  normal  histology  of  the  human  hemo- 
lymphglands.  American  Journal  of  Anatomy,  1  nov.  1901  ; — Journ.  of  the 
Boston  Soc.  of  tncd.  Sciences,  avril  1901  ; — Journ.  of  med.  Research,  July 
1901. — Morandi  et  Piato.  Arch,  per  le  Scienze  mediche,  vol.  XXV. 

Feb.,  1902. 


SECOND  PART 

Special  Study  of  the  Lymphatics  of  the  Body 

BY 

P.  POIRIER  AND  B.  CUNfiO 


WE  will  study  in  succession  : — 

1.  The  lymphatics  of  the  lower  limb  (chap.  i.). 

2.  „  „  „       pelvis  and  abdomen  (chap.  ii.). 

3.  ,,  ,,  ,,       thorax  (chap.  iii.). 

*•     „  „  ,,       upper  limb  (chap.  iv.). 

5-     ,,  „  ,,       head  and  neck  (chap.  v.). 

In  each  chapter  we  will  first  consider  the  different  glandular 
groups  and  the  arrangement  of  their  afferent  and  efferent  vessels. 
We  will  then  return  to  the  arrangement  of  the  lymphatics  of 
the  organs  and  the  tributary  regions  of  these  glands. 

We  will  terminate  this  portion  of  the  book  by  studying  the 
two  large  collecting  trunks  into  which  almost  all  the  lymphatic 
vessels  of  the  human  subject  eventually  pour  their  contents,  viz. 
the  thoracic  duct  and  right  lymphatic  duct  (chap.  vi.). 

CHAPTER  I 
THE  LYMPHATICS  OF  THE  LOWER  LIMB 

THE  lymphatic  vessels  of  the  lower  limb  are  arranged  in  two  groups  ; 
one  (the  superficial  lymphatics)  run  in  the  subcutaneous  cellular 
tissue,  the  other  (the  deep  lymphatics)  run  under  the  aponeurosis. 
All  converge  towards  the  inguinal  region,  where  they  terminate 
in  the  superficial  or  deep  inguinal  glands.  These  inguinal  glands 
thus  form  the  common  meeting  place  of  almost  all  the  lymphatics  of 
the  lower  limb.  However,  some  of  these  vessels  have  already  traversed 
certain  glands  of  much  less  importance,  it  is  true,  namely  the 
anterior  tibial  and  the  popliteal  glands.  We  will  first  of  all  describe 
the  arrangement  of  these  different  glandular  groups.  We  will 


112 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


Anterior  tibiil  gland 


then  give  a  description  of  all    the  lymphatic   vessels  of  the  lower 
limb. 

§  1.  GLANDULAR  GROUPS  OF  THE  LOWER  LIMB 

WE  will  study  in  turn    the  anterior  tibial,  the  popliteal,  and  the 

inguinal  glands. 

Anterior   Tibial    Gland.  —  The    anterior   tibial   gland,   described 

and  figured  for  the  first 
time  by  Mascagni  (loc. 
cit.  p.  39,  and  plate  vi. 
fig.  2),  is  always  very 
small.  It  is  placed  in 
the  course  of  the  anterior 
tibial  vessels  at  their 
upper  part ;  it  rests  on 
the  interosseous  ligament. 
It  is  generally  ad- 
mitted that  the  anterior 
tibial  gland  receives  an 
anterior  tibial  trunk,  as 
an  afferent,  and  gives  off 
an  efferent  which  ends  in 
the  popliteal  glands.  It 
would  be  perhaps  more 
correct  to  say  it  is  a 
simple  nodule  which  in- 
terrupts the  course  of  one 
of  the  anterior  tibial 
trunks  which  end  in  the 
popliteal  glands. 

VARIETIES. — The  existence 
of  the  anterior  tibial  gland  is 
far  from  being  constant. 
Cruikshank  and  Hunter 
make  no  mention  of  it. 
Bourgery  and  Leaf  regard 
it  as  very  inconstant.  On 
the  other  hand  it  may  be 
double  (Mascagni,  Hewson, 

FIG.  33. — Anterior  tibial  lymphatics  and  anterior  tibial  Meckel),   and  descend   as  far 
gland  (after  Bonamy,  Broca  and  Beau).  ag    the    middle   of    the    limb 

(Hewson). 

The  inconstancy  of   this  gland,  its  small   size,  its  variations  in   number 
and  situation,  clearly  prove  that  from  the  phylogenic  point  of  view  it  is  of 


Anterior  libi'il  trunk 


Anterior  pcronenl'artery 

Internal  plantar  tributary 
Dorsalis  pedis  tributary 
External  plantar  tributary 


THE    LYMPHATICS    OF    THE    LOWER    LIMB        113 


recent  formation.  In  fact,  it  is  not  so  much  a  gland  properly  so  called  as  a 
simple  interrupting  glandular  nodule  (Schaltdruse),  which  does  not  present 
the  morphological  fixity  of  the  regional  glands  (vide,  p.  86).  But  with 
our  present  knowledge  of  the  general  evolution  of  the  glandular  apparatus 
in  the  higher  vertebrates,  \ve  are  bound  to  admit  that  this  nodule  is  in 
process  of  being  raised  to  the  dignity  of  a  gland  properly  so  called.  In 
other  words,  its  increase  in  size,  and  its  division  into  two,  should  be 
regarded  as  progressive  anomalies,  its  reduced  size  and  its  disappearance, 
as  a  return  to  the  primitive  state. 

Popliteal  Glands. — All  the  popliteal  glands  are  sub-aponeurotic. 
As  they  are  nearly  always  very  small,  and  buried  in  the 
fatty  tissue  which  fills  the  popliteal  space,  they  are  difficult 
to  find  unless  their  afferent  vessels  have  been  previously  injected. 
They  may  be  divided  into  three  groups,  which  extend  from  the 
under  surface  of  the  aponeurosis  to  the  posterior  ligament  of 
the  knee  joint. 

(a)  A  primary  gland  is  generally  found  beneath  the  aponeurosis, 
external  to   the  terminal  portion  of  the  external  saphenous  vein, 
and  internal  to  the  external  popliteal  nerve.     This  is  the  external 
saphenous    gland.       Sometimes   this  gland  is  placed  at  a  higher 
level,    on   an 

anast  omo  tic 
branch  be- 
tween the 
external  and 
internal  sa- 
phenous vein. 

(b)  A    se- 
cond    group 
(the     middle 
glands), 
which    is    of 
much     more 
importance, 
comprises     2 
to    4    glands 
more    deeply 
situated     on 
the  lateral 
parts  of    the 
popliteal  ves- 
sels ;      these 


Internal  popliteal  nerve. 
Popliteal  vein. 

Popliteal  artery. 
External  popliteal  nerve. 

Supra — condyloid  gland. 


Inter — tondyloid  gland. 
Juxla-Saphenous  gland. 


FIG.  34.— Glands  of  the  popliteal  space. 


11 


114  SPECIAL    STUDY    OF    THE    LYMPHATICS 

glands  are  situated  some  external  to,  and  some  internal  to  the  ves- 
sels, and  often  form  two  distinct  masses  ;  one,  the  inferior,  is  placed  at 
the  level  of  the  condyles,  in  the  intercondyloid  space  (intercondy- 
loid  glands,  Leaf) ;  the  other,  the  superior,  is  situated  above  these 
bony  prominences  (supracondyloid  glands,  Leaf)  (vide  fig.  40). 

(c)  Finally,  a  gland  may  be  found  attached  to  the  posterior  ligament 
of  the  knee  joint,  in  front  of  the  artery  (juxta-articular  gland). 

AFFERENT  VESSELS. — In  each  of  these  glandular  groups,  distinct 
afferents  terminate.  The  external  saphenous  gland  receives 
the  vessels  which  accompany  the  external  saphenous  vein.  These 
vessels  come  from  the  posterior  third  of  the  external  border  of  the 
foot,  from  the  outer  part  of  the  heel,  and  from  the  posterior  surface 
of  the  limb. 

The  middle  glands  receive  (1)  the  afferent  lymphatics  of  the 
anterior  tibial  gland  ;  (2)  the  deep  lymphatics  which  accompany 
the  posterior  tibial  and  peroneal  vessels. 

The  juxta-articular  gland  receives  the  lymphatics  which  come 
from  the  knee  joint  and  accompany  the  articular  arteries 
(Bardeleben,  Naeckel  and  Frohse). 

EFFERENT  VESSELS. — The  efferent  vessels  of  the  popliteal  glands 
may  be  divided  into  two  groups. 

(a)  A  deep  group  which  comprises  2  to  4  trunks  which  follow 
the   popliteal    vein,  and    then    the    femoral  vein,  and   end  in  the 
deep  inguinal  glands. 

(b)  A  superficial  group  comprising  1  to  2  trunks  which  follow  the 
anastomotic  branches  between  the  external  and  internal  saphenous 
veins,  and  which   all  unite  with  the  satellite  trunks  of  this  vessel 
and  terminate  in  the  infero-internal  group  of  inguinal  glands.     This 
latter  route  is  less  important  than  the  former  and  may  be  absent. 

Bardeleben,  Naeckel  and  Frohse  admit  the  further  possibility  of 
a  third  efferent  route,  winch  if  present  accompanies  the  great  sciatic 
nerve. 

VARIETIES. — The  popliteal  glands  present  numerous  variations.  We  have 
taken  as  the  type  of  our  description  the  arrangement  which  has  appeared 
to  us  to  be  the  most  frequent.  Of  the  three  groups  which  we  have  described, 
the  most  constant  is  the  middle  group.  The  external  saphenous  gland  and  the 
juxta-articular  gland  are  not  infrequently  absent.  A  gland  is  sometimes 
found  abnormally  placed  on  the  fibrous  arch  of  the  soleus  muscle  (tibio- 
popliteal,  Bougery,  loc.  cit.  vol.  iv.,  plate  82). 

Inguinal  Glands. — The  inguinal  glands  are  much  more  numer- 
ous than  the  preceding,  and  constitute  one  of  the  more  important 
glandular  centres  of  the  body.  They  are  distinguished  as  super- 
ficial and  deep. 


THE    LYMPHATICS    OF    THE    LOWER    LIMB        115 

SUPERFICIAL  INGUINAL  GLANDS.— The  superficial  inguinal  glands 
occupy  the  whole  of  Scarpa's  triangle.  The  space  they  occupy 
is  limited  above,  by  Poupart's  ligament,  externally  by  a  vertical 
line  passing  through  the  anterior  inferior  iliac  spine,  internally,  by 
a  second  vertical  line  drawn  through  the  pubic  spine,  below,  by  a 
horizontal  line  placed  six  or  seven  centimetres  below  Poupart's 
ligament.  They  are  placed  in  the  deep  layer  of  the  superficial 
fascia,  and  are  in  relation  with  the  following  subcutaneous  organs  in 
this  region  :  the  subcutaneous  abdominal  arteries,  viz.  the  super- 
ficial circumflex  iliac,  superficial  external  pudic  ;  the  corresponding 
veins,  the  terminal  portion  of  the  internal  saphenous  vein,  and  the 
crural  branch  of  the  geni to-crural  nerve. 

The  number  of  these  glands  is  somewhat  variable.  Moreover, 
to  succeed  in  estimating  them  accurately  it  is  essential  that  their 
afferent  vessels  should  be  injected ;  for  injections,  and  more  particu- 
larly coloured  injections,  enable  us  to  discover  small  glands  Avhich  in 
a  simple  dissection  would  certainly  escape  notice.  It  may  then  be 
seen  that  they  vary  in  number  from  10  to  20  ;  their  size  is  no 
less  variable  than  their  number.  As  a  result  of  the  constant 
infections  to  which  they  are  exposed,  they  are  not  infrequently 
found  hypertrophied. 

On  account  of  their  number,  and  the  large  space  occupied  by 
these  glands,  the  majority  of  anatomists  divide  them  into  several 
groups.  We  must  remark,  however,  that  all  these  divisions  are 
absolutely  artificial.  On  the  one  hand,  all  of  them  as  a  matter  of 
fact  are  scattered  about  \vithoutapparent  order,  so  that  it  is  impos- 
sible to  group  them  into  distinct  masses,  characterized  by  a  constant 
topography.  On  the  other  hand,  though  each  of  the  different 
regions  whose  lymphatics  are  tributaries  of  the  inguinal  glands  send 
by  preference  their  vessels  to  certain  of  these  glands,  there  is  no 
arrangement  sufficiently  constant  to  serve  as  a  basis  for  a  natural 
classification.  We  recognize,  however,  the  necessity  for  dividing 
the  superficial  inguinal  glands  into  several  groups,  though  we  would 
again  insist  on  the  purely  conventional  nature  of  any  division. 

With  these  reservations,  we  will  adopt  the  following  classification, 
which  is  almost  identical  with  that  proposed  by  Quenu  and  since 
accepted  by  Gerota,  Bardeleben,  Naeckel,  and  Frohse,  etc. 

A  horizontal  line  passing  through  the  saphenous  opening,  divides 
the  superficial  inguinal  groups  into  two  groups  :  a  superior  and  an 
inferior.  A  vertical  line  passing  through  the  saphenous  opening, 
divides  each  of  these  groups  into  two  secondary  groups,  one  external 


116 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


>upert 

'      Superior  intermit  (/land. 
Inferior  intern-.il  y'-ini'J. 


and  the  other  internal.  Finally,  there  is  often  a  central  group, 
formed  by  1  to  3  small  glands  placed  in  the  actual  orifice  of  the 
internal  saphenous  opening.  According  to  Leaf,  it  is  not  unusual  to 
find  one  of  these  glands  embedded  in  the  fatty  laj^er  in  the  imme- 
»  diate  vicinity  of  the  saphenous  opening,  thus 

constituting  a  transition  between  the  super- 
ficial and 
the  deep 
glands. 

To  sum 
up  -  -  The 
superficial 
inguinal 
g  1  a  n  d  s 
m  ay  be 
divided 
into  five 
groups  : — 
( 1 )  supero- 
ex  ternal. 
(2) supero- 
internal, 
(3)  infero- 
internal 

( 4)  infero-ex  ternal.  (5)  central  group  (parasphenous  glands  of  Quenu  r  )• 
The  two  superior  groups  are  formed  by  a  series  of  glands  fairly 
regularly  arranged  below  the  crural  arch,  and  having  their  long  axis 
parallel  to  it.  The  arrangement  of  the  lower  groups  is  much 
more  irregular.  Though  the  lowest  are  usually  elongated  in  the 
vertical  direction,  parallel  to  the  axis  of  the  limb,  the  majority  of 
them  are  round  or  oval  and  irregularly  scattered  about. 

There  are  many  other  classifications  of  the  superficial  inguinal  glands. 
We  are  aware  of  the  classical  division  into  a  superior  or  horizontal  group  (in- 
guinal glands),  and  an  inferior  or  vertical  group  (crural  glands).  The  former 
would  receive  the  genital,  anal,  abdominal,  and  gluteal  lymphatics  :  the  latter, 
the  lymphatics  of  the  lower  limb*  Though  this  classification  may  suffice  from 
the  clinical,  it  does  not  do  from  the  anatomical  point  of  view.  There  are 
numbers  of  round  glands  situated  in  the  centre  of  this  region,  and  one  does 
not  know  in  which  group  they  should  be  included.  Moreover,  we  shall  shortly 
see  that  the  termination  of  the  afferent  lymphatics  is  far  from  being  as  syste- 
matic as  this  classification  would  seem  to  indicate.  Sappey  gives  a  different 
classification  which  we  think  it  advisable  to  mention  here,  because  it  has 
been  adopted  by  a  certain  number  of  authors.  He  describes  a  superior  group 
which  occupies  the  inguinal  region  ;  an  inferior  group,  the  glands  of  which 


Fro.  35. —Superficial   inguinal    glands. 

The    cribriform    fascia  Vicing  removed,  exposes  the 
upper  part  of  the  femoral  vessels. 


THE  LYMPHATICS  OF  THE  LOWER  LIMB  117 

are  placed  round  the  internal  saphenous  vein  ;  an  internal  group,  placed  within 
the  saphenous  opening  ;  an  external  group,  situated  external  to  the  termination 
of  this  vessel ;  and  finally  a  central  group,  which  has  no  fixed  position  or  relation. 
Aberrant  Glands. — We  may  frequently  come  across  aberrant  superficial 
inguinal  glands,  situated  external  to  the  region  which  we  have  indicated 
above  as  being  their  more  usual  site.  Thus  Au spitz  has  observed  the 
possible  presence  of  little  glands  below  the  anterior  superior  iliac  spine 
(extra-inguinal).  Similarly,  Lejars  lias  come  across  glands  placed  above  the 
crural  arch  and  beneath  the  abdominal  skin  (supra-inguinal). 

AFFERENT  VESSELS. — The  superficial  inguinal  glands  receive  the 
cutaneous  lymphatics  of  the  lower  limb,  the  perineum,  the  scrotum, 
the  penis,  the  prepuce  of  the  clitoris,  the  anus,  and  the  sub-umbilical 
portion  of  the  abdominal  wall.  According  to  Sappey,  the  lymphatics 
of  the  glans  penis,  and  glans  clitoridis  both  throw  themselves  into 
the  superficial  inguinal  glands  ;  but  we  shall  see  further  on  that  this 
termination  is  exceptional  and  that  these  vessels  are  normally 
tributaries  of  the  deep  inguinal  glands  (vide  pp.  156  and  159).  It  was 
formerly  an  accepted  fact  that  each  of  the  lymphatic  territories 
which  we  are  to  describe,  corresponds  to  a  definite  glandular  group  ; 
and  it  was,  and  for  good  reason,  still  is  the  custom  to  teach  that,  in 
certain  symptomatic  adenopathies  it  is  possible,  from  the  form  and 
situation  of  the  infected  glands,  to  diagnose  with  certainty  the 
position  of  the  lesion.  We  will  not  repeat  the  different  classifications 
which  have  been  proposed,  as  none  of  them  sufficiently  indicate  the 
facts.  Recent  researches  have  in  fact  satisfactorily  shewn  that  the 
division  of  the  inguinal  glands  into  several  groups  is  only  of  value  for 
the  sake  of  convenience,  and  that  the  lymphatics  which  come  even 
from  the  same  region,  may  terminate  in  different  groups  ;  thus  the 
lymphatics  of  the  lower  limb  terminate  both  in  the  infero-external 
and  in  the  infero-internal  group. 

Similarly,  the  lymphatics  of  the  scrotum  and  the  coverings  of  the 
penis  usually  end  in  the  supero-internal  group,  but  they  may  also  end 
in  the  glands  of  the  infero-internal  group  (vide  p.  153).  The  same 
holds  good  for  the  lymphatics  of  the  prepuce  of  the  clitoris,  the 
iabia  majora  and  minora  (Bruhns)  (vide  p.  158). 

The  lymphatics  of  the  perineum  terminate  in  the  supero-external 
and  supero-internal  groups. 

The  lymphatics  of  the  anus  usually  pass  into  the  supero-internal, 
but  may  terminate  in  the  infero-external  glands,  or  again  they  may 
be  tributaries  to  these  two  groups  at  the  same  time ;  it  is  equally 
possible,  though  perhaps  rather  exceptional,  to  see  one  or  several 
of  them  reach  the  central,  or  one  of  the  external  groups  (Quenii, 
Gerota)  (vide  pp.  188  and  189). 


118 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


The  cutaneous  lymphatics  of  the  umbilicus  and  of  the  sub  umbilical 
portion  of  the  abdominal  wall  end  in  the  supero-internal  and  supero- 
external  glands  (Bruhns,  Cuneo  and  Mareille)  (vide  pp.  149  and  150). 


FIG  36. — Glands  of  the  inguinal  region;  afferent  and  efferent  lymphatics  (taken  from 
Sappey's  atlas). 

1,1.  The  two  lowest  glands  of  the  inguinal  region — both  remarkable  for  their  size. — 2. 
Infero-external  gland.  3,3.  Internal  inguinal  glands  to  which  pass  the  lymphatics  of  the 
scrotum,  perineum,  the  anal  region,  and  the  supero-internal  part  of  the  integuments  of  the 
thigh. — 4.  Supero-internal  inguinal  gland ;  it  receives  vessels  coming  from  the  urethra,  and 
from  the  surface  of  the  glans  and  coverings  of  the  penis. — 5,5.  Supero-internal  and  external 
inguinal  glands,  into  which  three  or  four  lymphatics  from  the  sub-umbilical  portion  of  the 
abdomen  terminate. — 6,6.  Lymphatic  vessels  from  the  antero-internal  portion  of  the  thigh. 
— 7,7.  Vessels  from  the  external  portion  of  the  thigh. — 8,8.  Vessels  from  the  gluteal  region. 
—  d,9.  Vessels  from  the  lumbar  region. — 10,  10,  10.  Vessels  from  the  sub-umbilical  portion 
of  the  anterior  wall  of  the  abdomen. — 11,11.  Lymphatic  vessels  of  the  scrotum. — 12. 
Lymphatic  vessels  of  the  prepuce. — 13,  13.  Lymphatic  vessels  of  the  coverings  of  the  penis. 
— 14.  Lymphatic  trunk  which  surrounds  the  corona  of  the  glans. — 15.  Median  trunk  which 
continues  the  course  of  the  preceding. — 16.  Umbilicus. 


The  lymphatics  of  the  buttock  generally  terminate  in  the  supero- 
external  group,  but  may  also  end  in  the  infero-external  glands. 

EFFERENT  VESSELS. — The  efferent  vessels  of  the  superficial  ingui- 
nal glands  end  in  the  deep  inguinal,  or  in  the  external  iliac  glands.  To 


THE    LYMPHATICS    OF    THE    LOWER    LIMB        119 

reach  these  glands  they  must  pass  through  the  femoral  sheath  : 
there  are  numerous  orifices  through  which  they  pass,  which  give  to 
the  upper  part  of  this  sheath  its  characteristic  stippled  appearance. 

The  efferents  which  terminate  in  the  deep  inguinal  glands  are  the 
least  numerous.  They  come  especially  from  the  glands  of  the  two 
lower  groups. 

The  efferents  which  terminate  in  the  pelvis  are  much  more  im- 
portant ;  they  vary  in  number  from  8  to  12,  and  are  always  of 
considerable  calibre.  They  pass  into  the  pelvic  cavity  through  the 
crural  ring,  and  accompany  the  femoral  vessels.  Some  of  them 
pass  in  front  of  these  vessels,  but  the  majority  run  along  the  inner 
part  of  the  ring,  internal  to  the  femoral  vein.  At  this  point,  some 
of  them  may  be  interrupted  by  the  gland  of  Cloquet;  but  the 
majority  end  in  two  glands,  viz.  the  external  and  internal  retro- 
crural  (vide  pp.  130  and  131,  fig.  41). 

DEEP  INGUINAL  GLANDS. — The  deep  inguinal  or  sub-aponeurotic 
glands  are  much  less  important  than  the  superficial  glands.  They 
vary  in  number  from  1  to  3,  and  are  not  usually  of  large  size. 
In  order  to  understand  their  precise  arrangement  and  relations, 
their  afferent  vessels  must  be  injected.  It  can  then  be  seen 
that  these  glands  are  placed  internal  to  the  femoral  vein.  When 
there  are  three  of  them,  the  lowest  is  placed  below  the  point  where 
the  external  saphenous  joins  the  femoral  vein.  The  supra jacent 
gland  is  lodged  in  the  crural  canal.  Finally,  the  superior  gland 
occupies  the  external  part  of  the  crural  canal,  and  protrudes  through 
the  septum  crurale  into  the  pelvic  cavity.  It  is  continuous  in  the 
pelvis  with  the  internal  chain  of  external  iliac  glands  (vide  p.  132). 
This  gland  of  the  crural  ring,  from  the  clinical  point  of  view,  has  a 
certain  amount  of  interest,  for,  on  account  of  its  situation,  it  may 
become  inflamed,  and  may  then  simulate  a  strangulated  femoral 
hernia.  French  authors  generally  call  it  the  gland  of  Cloquet 
while  the  Germans  call  it  the  gland  of  Rosenmiiller. 

AFFERENT  VESSELS. — The  deep  inguinal  glands  receive  :— 

1.  Some  of  the  afferents  from  the  superficial  inguinal  glands. 

2.  The  deep  lymphatics  which  accompany  the  superficial  femoral 
vessels. 

3.  The  deep  lymphatics  which  accompany  the  deep  femoral  vessels. 

4.  The  lymphatics  from  the  glands  in  the  male,  and  the  clitoris 
in  the  female. 

EFFERENT  VESSELS.— The  efferent  vessels  penetrate  into  the  pelvic 
cavity  and  almost  all  terminate  in  the  retro-crural  internal  gland. 


120  SPECIAL    STUDY    OF    THE    LYMPHATICS 

One  or  two  may,  however,  end  in  the  retro-crural  external  gland. 

The  most  inconstant  of  these  glands  is  the  middle  gland.  The  gland  of 
Cloquet  is  also  not  uncommonly  absent.  Moreover,  the  total  absence  of  the 
deep  inguinal  glands  is  far  from  being  rare,  but  this  statement  cannot  be 
made  unless  the  deep  femoral  lymphatics  have  previously  been  injected. 
Unless  this  precaution  is  taken,  these  glands,  which  are  lost  in  the  fat,  may 
not  be  recognized.  In  our  view,  certain  authors,  such  as  Auspitz,  are  quite 
wrong  in  regarding  their  absence  as  the  rule. 

Owing  to  the  small  size  and  inconstancy  of  the  deep  inguinal  glands,  Stahr 
regards  them  as  simple  nodules  (Schaltdriise),  interposed  in  the  course  of  the 
deep  lymphatics  of  the  lower  limb  (Stahr).  This  way  of  regarding  them,  we 
think  incorrect,  for  it  is  at  variance  with  the  fact  that  the  deep  inguinal 
glands  have  other  afferents  than  the  femoral  trunks,  seeing  that  they 
receive  the  deep  lymphatics  from  the  penis  and  clitoris  (Marcille).  They 
are  therefore  true  regional  glands.  On  the  other  hand,  we  must  recognize 
that  the  number  and  size  of  these  glands  is  by  no  means  proportionate  to  the 
importance  of  the  deep  femoral  lymphatics :  and  it  is  difficult  to  understand 
what  error  caused  Bourgery  to  estimate  these  glands  as  six  or  eight  in  number. 

The  gland  figured  by  Bourgerj^  in  the  course  of  the  internal  circumflex 
vessels  (Bourgery,  loc.  cit.  vol.  4,  plate  82),  and  one  or  two  small  glands 
which  are  sometimes  met  with  in  the  course  of  the  femoral  vessels  in  the 
middle  part  of  the  thigh  may  be  regarded  as  aberrant  elements  of  this  group. 

Upon  the  topography  of  the  inguinal  glands  vide  Mascagni,  loc.  cit.  p.  37 
et  Tab.,  iv,  viii,  x. — Sappey,  loc.  cit.  p.  G3  et  pi.  vii,  viii  et  xi. — 
Auspitz,  die  Bubonen  der  Leistengegend,  Arch  f.  Dermat,  u.  Syphilis,  1873, 
Bd  v,  p.  443.— Zeissl  u.  Horowitz,  IKtener  klin.  Wochcnschr.,  1890,  p.  388, 
et  Wiener  medicin.  Presse,  Bd  xxxviii,  p.  761. — Leaf,  loc.  cit.,  p.  67. — 
Felizet,  Note  clinique  sur  les  ganglions  cVaboutissement  des  membres,  Bull. 
Soc.  Chir.,  1893,  p.  521. — Quenu,  Journal  de  I  Anat. f  1893,  11.  4,  p.  523.— 
Bruhns.  Ueber  die  Lymphgefasse  der  aiisserem  mannlichen  Genitalien.  u. 
der  Zuflusse  der  Leisteiidriisen,  Arch.  /.  Anat.  u.  Phys.,  Anat.  Abth.,  1900. 
p.  281. 

§  2.     LYMPHATIC    VESSELS    OF    THE    LOWER    LIMB. 

As  we  have  seen  above,  we  may  divide  the  lymphatics  of  the  lower 
limb  into  superficial  lymphatics,  which  take  origin  in  the  integuments, 
the  collecting  trunks  of  which  run  in  the  subcutaneous  cellular  tissue, 
and  into  deep  lymphatics  which  arise  in  the  sub-aponeurotic  organs, 
and  end  in  trunks  which  closely  accompany  the  vessels  and  nerves. 

Superficial  Lymphatics. — The  superficial  lymphatics  emerge 
at  all  points  from  the  cutaneous  envelope  of  the  limb  ;  but  it  is 
in  the  foot  that  the  network  of  origin  presents  its  maximum  de- 
velopment. It  is  in  this  situation  too,  and  particularly  on  the 
lateral  surfaces  of  the  toes  and  margins  of  the  sole  of  the  foot, 
that  the  attempt  must  be  made  to  inject  these  vessels.  On  the 
other  hand,  in  the  rest  of  the  limb,  with  the  exception  perhaps,  of 
the  prae-patellar  region,  the  network  of  origin  has  extremely  fine 
meshes,  and  its  injection  offers  great  difficulties. 


THE    LYMPHATICS    OF    THE    LOWER    LIMB        121 

The  collecting  trunks  which  come  from  this  network  may  be 
divided  into   three  groups:     (1)   the  collectors  which  accompany 
the    internal     saphenous     vein, 
which     are    tributaries     of    the 
inguinal  glands  and  which  drain 
almost  the  entire  cutaneous  sur- 
face  of    the  lower  limb  ;   (2)  the 
collecting   trunks  which  accom- 
pany   the     external    saphenous 
and    which    end     in     the 


FIG.  37. — The  superficial  lymphatic  vessels  of  the  foot  (after  Sappey), 
1.1.  Lymphatic  network  of  the  external  border  of  the  foot. — 2,2.  Lymphatic  network  of 
the  toes. — 3.  Lymphatic  network  of  the  skin  of  the  heel. — 4,  4,  4,  4.  Lymphatic  vessels 
which  accompany  the  external  saphenous  vein  and  terminate  in  the  popliteal  glands. — 
5,  5,  5.  Lymphatic  trunks  on  the  dorsal  surface  of  the  foot. — 6,6.  Lymphatic  trunks  which 
run  from  the  external  towards  the  internal  surface  of  the  limb. — 7,  7,  7,  7.  Networks  from 
each  of  which  runs  a  little  trunk,  which  terminates  in  one  of  the  neighbouring  trunks. 

popliteal  glands  ;   (3)  the  collecting  trunks  of  the  gluteal  region. 

(1)      TlIE  COLLECTING  TRUNKS    WHICH    FOLLOW     THE    COURSE     OF 

THE  INTERNAL  SAPHENOUS  VEIN. — These  collecting  trunks  first 
appear  in  the  toes.  From  the  network  which  covers  them, 
spring  a  considerable  number  of  little  trunks,  some  of  which  run 
towards  the  internal  surface,  and  others  towards  the  external 
surface  of  each  toe,  from  both  the  dorsal  and  plantar  aspect. 

;;In  joining  together,  the  dorsal  and  palmar  trunks  constitute 
on  each  lateral  surface  two  principal  trunks,  parallel  to  the  corre- 
sponding collateral  artery,  above  which  they  are  situated.  At 
the  level  of  the  metatarso-phalangeal  articulations,  these  trunks 
communicate  with  each  other  in  various  ways  ;  sometimes,  the 
external  collaterals  of  one  toe  unite  with  the  internal  collaterals 
of  a  neighbouring  toe  ;  and  sometimes,  the  four  trunks  from  the  same 


122 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


toe  unite  to  form  a  single  trunk  which  divides  a  little  farther  up  into 
two  trunks  which  blend  with  the  trunks  which  are  nearest  to  them. 

From  these  communications  a  large 
plexus  results,  the  elongated  meshes  of 
which,  from  before  backwards,  are  spread 
•14  out  under  the  integuments  on  the  dorsal 
surface  of  the  foot"  (Sappey).  In  each 
interdigital  space,  this  dorsal  plexus  is 
augmented  by  the  trunks  coming  from 
the  plantar  region.  These  trunks,  three 
or  four  for  each  space,  originate  at 
the  level  of  the  heads  of  the  metatarsal 
bones,  the}r  converge  from  behind  for- 
wards towards  the  interdigital  spaces, 
and  then  bend  round  to  gain  the  dorsal 
surface  of  the  foot. 

From  this  dorsal  network,  several  col- 
lecting trunks  arise  which,  with  Sappey, 
we  may  divide  into  internal  and  external. 
The  internal  collecting  trunks  arise  from 
the  two  inner  toes  and  from  the  internal 
third  of  the  dorsal  network.  Immediately 
after  their  origin,  they  are  augmented  by 
the  internal  plantar  trunks  which,  as  they 
turn  round  the  internal  border  of  the 
foot,  number  about  twelve  to  fifteen, 
but  become  reduced  to  four  or  five 
after  their  arrival  on  the  dorsal  surface 


of    the    foot.       The     internal 


collecting 


1,  1.  Lymphatic  network  of  the  internal  portion  of  the 
sole  of  the  foot. — 2,  2.  Lymphatic  vessels  which  run 
from  it. — 3.  Other  lymphatic  trunks  of  the  dorsal  surface 
of  the  foot. — 4.  Large  trunk  which  passes  in  front  of 
the  internal  malleolus. — 5,  5.  Vessels  situated  in  front 
of  and  behind  this  trunk. — 6,  6.  Vessels  coming  from  the 
external  surface  of  the  limb. — 7,  7.  General  view  of  lym- 
phatic vessels  situated  on  the  internal  surface  of  the 
iimb. — 8.  Vessels  bending  round  the  postero-internal 
part  of  the  knee. — 9.  Vessels  which  skirt  the  front  of  the 
articulation  ;  they  differ  from  the  preceding  in  their 
sinuosities. — 10,  10.  Vessels  which  take  origin  from  the 
posterior  portion  of  the  thigh. — 11,  11.  Vessels  which 
come  from  the  an tero -external  part. — 12,  12.  Group 
of  trunks  which  correspond  to  the  ant ero -internal  part. — 

13.  Large  glands  in  which  the  majority  of  superficial  lymphatics  of  the  lower  limb  end. 

— 14,  14.  Superior  inguinal  glands. — 15,  15.    Inferior   inguinal   glands;    their   afferent   and 

efferent  vessels. 


FIG.  38. — The  superficial  lymph- 
atics of  the  internal  surface  of 
the  lower  limb  (after  Sappey). 


THE    LYMPHATICS    OF    THE    LOWER    LIMB        123 


trunks    then   run    upwards,    being    grouped    round   the    internal 

saphenous  vein  to  which  they  run  parallel ;   for  the  most  part  they 

are  placed  either  in  front  of  or  behind 

this  vein  ;  some  of  them  may,  however, 

cover  it,  or  even  be  inserted  between 

its  deep  surface  and  the   aponeurosis. 

They  thus  pass  as  far  as   the  inguinal 

glands. 

The  external  collecting  trunks  arise 
from  the  three  outer  toes,  from  the 
outer  two- thirds  of  the  dorsal  surface, 
and  from  the  anterior  half  of  its  exter- 
nal border.  Their  arrangement  is  very 
different  to  that  of  the  internal  trunks. 
Instead  of  passing  up  vertically  as  the 
latter  do,  and  being  arranged  in  parallel 
columns,  the  external  collecting  trunks 
divide  into  secondary  trunks  which  run 
in  succession  upwards  and  inwards  to 
end  in  the  internal  collecting  trunks. 
A  comparison  of  fig.  38  with  fig.  39 
well  shows  the  difference  between  the 
collecting  trunks  on  the  external  and 
internal  surface  of  the  limb. 

(2)  COLLECTING  TRUNKS  WHICH  FOLLOW 
THE  COURSE  OF  THE  EXTERNAL  SAPH- 
ENOUS VEIN. — These  vessels  take  origin 
from  the  posterior  half  of  the  external 

1,1.  Lymphatic  network  of  the  external  border  of 
the  foot. — 2,  2.  Two  trunks  springing  from  it  ;  they 
pass  backwards,  and  end  in  the  popliteal  glands. — 3, 
3.  Lymphatic  vessels  of  the  dorsal  surface  of  the 
foot  coming  from  the  toes  and  from  the  anterior 
portion  of  the  plantar  region. — 4,  4.  Vessels  which 
cross  the  crest  of  the  tibia,  almost  all  of  which  come 
from  one  and  the  same  trunk,  which  divides  and 
subdivides  ;  they  are  sinuous  and  frequently  anasto- 
mose in  their  course. — 5,  5.  These  are  also  very  sinu- 
ous vessels  which  pass  in  front  of  the  knee. — 6,  6.  Vessels 
•which  skirt  the  antero-external  part  of  the  knee  joint, 
they  are  also  remarkable  for  their  sinuosities. — 7,  7; 
Lymphatic  vessels  coming  from  the  posterior  portion  Fio  39  —Superficial  lymphatics  of 
of  the  thigh.— 8,  8.  Trunks  which  course  along  the  the  external  surface  of  the  lower 
antero-internal  surface  of  the  th.gh.— 9,  9.  Trunks  limb  (after  Sappey). 
which  correspond  to  its  antero-external  portion. — 

10,  10.  Large  glands  in  which  the  majority  of  superficial  lymphatic  vessels  of  the  upper  limb 
end. — 11,  11.  Superior  inguinal  glands  ;  they  are  generally  four  in  number,  and  are 
arranged  in  linear  series. — 12,  12.  Other  inguinal  glands  with  afferent  vessels. 


124  SPECIAL    STUDY    OF    THE    LYMPHATICS 

border  of  the  foot,  and  from  the  corresponding  portion  of 
the  heel.  From  two  to  three  in  number,  they  run  at  first  like 
the  external  saphenous  vein  between  the  external  malleolus  and 
the  tendo  Achillis,  which  they  more  or  less  closely  embrace.  Here 
they  receive  the  lymphatics  from  the  inferior  part  of  the  posterior 
surface  of  the  limb.  Always  in  close  contact  with  this  vein  they 
are  placed,  like  it,  in  the  space  between  the  two  gastrocnemii.  In 
the  upper  part  of  their  course,  they  become  sub-aponeurotic, 
and  receive  no  more  cutaneous  branches.  They  terminate  in  the 
juxta-saphenous  gland  which  is  the  most  superficial  of  all  the 
popliteal  glands  (vide  p.  113). 

(3)  COLLECTING  TRUNKS  FROM  THE  GLUTEAL  REGION.— The 
collecting  trunks  from  the  gluteal  region  may  be  divided  into  two 
groups, — external  and  internal. 

(a)  The    external  are  the  most  important.     They  arise  from 
the  outer  two- thirds  of  this  region.     They  run  at  first  do  Avn  wards, 
outwards  and  forwards ;  they  then  turn  round  the  great  trochanter 
and  eventually  terminate  in  the  supero-external  group  of  superficial 
inguinal  glands. 

(b)  The  internal  collecting  trunks  only   drain  the  inner  third 
of   the   buttock.     They  unite   with   the   vessels   coming  from   the 
integuments  of  the  anal  region  (vide  p.   187).       Like  the  latter, 
they  run  downwards  and  forwards,  and  turning  round  the  upper 
part  of  the  thigh  they  end  in  the  supero-internal,  and  infero-internal 
groups  of  superficial  inguinal  glands. 

Deep  Lymphatics. — The  deep  lymphatics  of  the  lower  limb 
may  with  sufficient  accuracy  be  styled,  "  satellites  "  of  the  blood 
vessels.  They  comprise  a  principal  channel  which  at  first  follows 
the  different  arterial  trunks  of  the  leg,  and  then  keeps  close 
to  the  popliteal  and  the  femoral  vessels,  and  accessory  channels, 
which  are  satellites  of  the  obturator,  ischiatic  and  gluteal  vessels. 

THE  PRINCIPAL  CHANNEL. — In  the  foot  and  in  the  leg,  the  deep 
lymphatics  may  therefore  be  divided  into  three  groups  :  the  pedal 
and  anterior  tibial  lymphatics,  the  plantar  and  posterior  tibial 
lymphatics,  and  the  peroneal  lymphatics. 

The  pedal  and  anterior  tibial  lymphatics  arise  from  the  sole  of 
the  foot.  The  small  trunks  from  which  they  originate  spring  from 
the  deep  plantar  muscles.  They  unite  into  one  or  two  trunks 
which  run  towards  the  dorsal  surface  of  the  foot,  keeping 
close  to  the  communicating  branch  between  the  external  plantar 
and  dorsalis  pedis  arteries.  They  then  embrace  the  latter  vessel 


THE    LYMPHATICS    OF    THE    LOWER   LIMB        125 


Femoral  trunks 


Popliteal  gland 


Popliteal  trunks 


closely,  and  afterwards  the  anterior  tibial.  After  being  interrupted 
in  the  anterior  tibial  gland,  they  continue  their  course  and 
never  leaving  the  anterior  tibial  artery,  terminate  in  the 
middle  group  of  popliteal  glands.  In  their  course,  they  collect 
all  the  deep  lymphatics  of  the  dorsal  surface  of  the  foot  and 
anterior  aspect  of  the  leg. 

The  plantar  and  posterior 
tibial  lymphatics  appear  in  the 
sole ;  they  follow  the  two 
plantar  arteries,  then  the  pos- 
terior tibial,  and  terminate  in 
the  same  glands  as  the  pre- 
ceding. It  is  in  these  glands 
that  the  peroneal  lymphatics, 
satellites  of  the  vessels  of  this 
name,  terminate. 

After  being  interrupted  in 
the  popliteal  glands,  all  these 
vessels  pass  upwards,  embrac- 
ing the  femoral  vein.  The 
latter  is  usually  accompanied 
by  four  or  five  trunks,  some 
of  which  are  placed  in  front 
and  some  internal  to  it.  Ac- 
cording to  our  own  observa- 
tions, one  or  two  small  glands 
may  be  met  with,  in  the 
course  of  these  vessels  in  the 
region  of  the  middle  of  the 
thigh.  These  vessels  terminate 
in  the  deep  inguinal  glands. 

Accessory  Channels.  —  The 
obturator  lymphatics  which 
arise  in  the  adductor  muscles, 
are  placed  in  the  obturator 
foramen,  and  terminate  in  the 
obturator  gland  when  this  is 

present,  or  in  the  middle  gland  FlG.  40^lDeep  lymphatics  of 

of  the  internal  chain  of  the  ex-  the  posterior  surface  of  the 

limb  (after  Bourgery). 

ternal  iliac  group  (vide  p.  132). 

The  ischiatic  lymphatics,  satellites  of  the  artery  of  this  name, 

i 


Posterior' tibial 
trunks 


Peroneal  trunks 


Posterior  tibinl 
trunks 


126  SPECIAL    STUDY    OF    THE    LYMPHATICS 

end  in  a  hypogastric  gland ;  this  terminal  gland  rests  on  the 
anterior  trunk  of  the  internal  iliac  artery  (vide  p.  135).  During 
their  extra-pelvic  course,  the  ischiatic  vessels  traverse  some  small 
glands  placed  below  the  pyriformis  muscle  (vide  Bourgery,  loc.  cit. 
plate  82). 

The  lymphatics  of  the  gluteal  region  come  from  the  gluteal  and  the 
pelvi-trochanteric  muscles ;  they  terminate  in  an  intra-pelvic  gland, 
placed  on  the  actual  trunk  of  the  artery,  at  the  upper  border  of 
the  great  sacrosciatic  notch  (vide  p.  135  and  fig.  43).  Like  the 
preceding,  they  present  in  their  course  six  to  ten  small  interrupting 
glandular  nodules  (Mascagni,  Sappey). 

ANASTOMOSES. — The  superficial  and  deep  lymphatics  are  clearly 
independent  of  each  other.  Mascagni,  however,  saw  one  of  the 
superficial  trunks,  a  satellite  of  the  internal  saphenous  vein,  pierce 
the  fascia  lata  in  the  middle  third  of  the  thigh  and  anastomose 
with  the  deep  lymphatics  (Mascagni,  loc  cit.  tab.  iv.  fig.  2). 
Bonamy,  Broca,  and  Beau  figure  a  similar  arrangement  (loc  cit., 
t.  11,  plate  45,  fig.  2).  Sappey  on  the  other  hand,  declares  that 
he  was  never  able  to  prove  the  existence  of  an  anastomosis  between 
the  superficial  and  the  deep  lymphatics.  It  is,  however,  important 
to  notice  that  the  efferent  vessel  which  the  popliteal  glands  send 
to  the  superficial  inguinal  glands  (vide  p.  114)  constitutes  a  true 
anastomosis  between  the  deep  and  the  superficial  lymphatics. 
This  exception,  however,  does  not  invalidate  the  rule,  and  as  a  general 
proposition  we  may  still  maintain  the  independence  of  the  superficial 
and  deep  lymphatic  apparatus. 

Technique1 — We  will  now  describe  in  detail  the  mode  of  injecting  the 
lymphatics  of  the  lower  limb  ;  we  will  in  fact  indicate,  in  connection  with 
this  subject,  the  general  rules  which  govern  the  injection  of  the  superficial 
and  deep  lymphatics  of  the  limbs,  and  the  walls  of  the  splanchnic  cavities. 
Sappey  laid  down  minute  rules  for  the  injection  of  the  lymphatics  of  the 
lower  limb  with  mercury.  We  will  now  merely  reproduce  his  instructions,  and 
then  add  a  few  words  on  the  application  of  Gerota's  method  to  the  lower  limb 
in  particular.  We  will  consider  in  turn  the  injection  of  the  superficial  and 
the  deep  lymphatics. 

The  Superficial  Lymphatics. — To  inject  the  superficial  lymphatics,  it  is 
important  to  select  a  somewhat  spare  subject,  aged  from  about  fifteen  to 
twenty.  Wet  compresses  are  first  applied  to  the  foot,  to  provoke  a  certain 
amount  of  maceration  of  the  epidermis.  The  latter  is  then  raised  by 
scraping  the  skin  with  a  convex  scalpel.  This  removal  of  the  softened 
epidermis  by  scraping  is  of  the  utmost  importance;  its  object  being  to  pre- 


1  On  General  Technique,  vide  p.   1118. 


THE    LYMPHATICS    OF    THE    LOWER    LIMB        127 

vent  the  blocking  of  the  mouth  of  the  injection  tube,  which  is  bound  to  take 
place  if  the  horny  layer  is  left  in  place.  A  column  of  30  to  40  centi- 
metres of  mercury  is  used. 

The  first  punctures  are  made  on  the  lateral  aspects  of  each  toe,  at  the 
junction  of  the  second  and  third  phalanges.  The  puncture  should  be  entirely 
superficial,  and  should  hardly  reach  the  subpapillary  layer  of  the  skin.  If 
the  point  has  been  well  directed,  we  shall  immediately  see  a  small  ash 
coloured  spot  appear  round  the  punctured  point,  which  shows  that  the 
mercury  has  penetrated  the  lymphatic  network.  If,  at  the  end  of  a  few 
moments,  this  characteristic  spot  does  not  make  its  appearance,  it  is  useless 
to  persist,  and  a  fresh  puncture  must  be  made.  It  is  important,  however, 
not  to  make  too  many  punctures,  for  each  one  opens  up  the  network  of 
origin,  and  thus  causes  a  number  of  very  small  leakages,  through  which  the 
mercury  escapes.  After  the  injection  of  the  toes,  the  sole  of  the  foot  must 
be  punctured  at  many  points,  and  more  especially  in  the  neighbourhood 
of  its  external  and  internal  borders. 

In  this  way  the  networks  of  origin  and  the  trunklets  which  arise  therefrom 
may  be  filled  without  much  difficulty.  Sometimes  the  mercury  may  actually 
be  seen  to  pass  into  the  large  collecting  trunks,  and  reach  the  inguinal 
glands;  but  it  is  usually  impossible  to  succeed  in  injecting  the  entire  lym- 
phatic system  of  the  lower  limb  at  the  first  attempt.  In  this  case  one  of  the 
trunks  originating  from  the  toe  must  be  sought  for  by  carefully  removing 
the  skin  from  the  dorsal  surface  of  the  foot,  and  the  collecting  trunk  thus  found 
must  then  be  injected.  The  same  process  may  be  repeated  on  one  or  several 
of  the  trunks  which  spring  from  the  external  and  internal  borders  of  the  foot, 
and  in  this  way  almost  all  the  collecting  trunks  of  the  lower  limb  may  be 
filled. 

The  skin  is  next  carefully  removed  from  the  limb,  working  from  below 
upwards,  and  the  vessels  now  filled  with  mercury  are  dissected,  the  usual 
rules  being  followed  (vide  pages  59  and  60).  The  limb  is  then  allowed  to 
dry  in  the  horizontal  position  ;  but  when  the  drying  process  is  almost 
completed,  the  vertical  position  must  be  maintained. 

In  order  to  inject  the  superficial  lymphatics  by  Gerota's  method,  we  pro- 
ceed in  the  same  way  as  for  the  injection  by  mercury.  The  sudden  appear- 
ance of  a  blue  tinge  round  the  puncture  will  shew  that  the  injected  material 
has  passed  into  the  networks.  We  should  remark  that  in  this  particular 
case,  the  method  of  Gerota  has  no  great  advantages  over  mercury,  except 
perhaps  in  newborn  subjects,  in  which  we  can,  in  certain  favom'able  cases, 
obtain  an  injection  of  almost  all  the  superficial  lymphatics  of  the  lower  limb 
by  making  two  or  three  punctures. 

Deep  Lymphatics. — The  injection  of  the  deep  lymphatics  is  a  much 
more  delicate  process,  for  with  mercury,  at  any  rate,  it  is  practically 
impossible  to  fill  them  by  direct  puncture  of  their  networks. 

To  inject  them  we  use  Mascagni's  method.  A  young  and  somewhat 
spare  subject  is  selected  for  preference,  into  whose  arteries  and  veins 
an  injection  of  gelatine  is  made.  The  injected  mass  to  some  extent  always 
transudes  through  the  vascular  walls  and  penetrates  into  the  lymphatic 
vessels,  which  it  renders  more  apparent ;  one  of  the  latter  is  then  punctured 
directly,  and  very  hot  water  run  over  the  preparation  to  liquify  the 
gelatine.  The  mercury  then  penetrates  into  the  deep  vessels  without 
difficulty. 

With  Gerota's  mixture,  we  may  sometimes  fill  the  deep  lymphatics  by 
directly  puncturing  the  fleshy  portion  of  the  different  muscles,  or  by 


128  SPECIAL    STUDY    OF    THE    LYMPHATICS 

superficially  puncturing  certain  tendons,  such  as  the  tendo  Achillis,  for  ex- 
ample; but  we  must  recognize  the  fact  that  these  injection  trials  made 
through  the  medium  of  the  networks  of  origin,  usually  end  in  failure  ;  on 
the  other  hand,  it  is  relatively  easy  to  inject  the  satellite  trunks  of  the 
femoral  vessels  by  directly  puncturing  one  of  the  popliteal  glands. 


CHAPTER  II 
LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN 

WE  will  study  (1)  the  glandular  groups  of  the  pelvis  and  abdomen  ; 
(2)  the  lymphatic  apparatus  of  the  different  organs,  the  vessels  of 
which  are  the  tributaries  of  these  glands. 

§  1.  GLANDULAR    GROUPS    OF    THE    PELVIS    AND 

ABDOMEN 

Though  the  lymphatic  glands  of  the  pelvis  are  continuous  without 
line  of  demarcation  with  the  abdominal  glands,  we  will  divide  them, 
for  convenience  of  our  description,  into  two  groups,  separated  by 
an  imaginary  horizontal  line  passing  through  the  bifurcation  of 
the  aorta  ;  an  inferior  group  (ilio-pelvic) ;  and  a  superior  group 
(abdomino-aortic). 

1.  ILIO-PELVIC  GLANDS. 

Under  the  name  of  ilio-pelvic  glands,  we  will  describe  the  glands 
situated  within  the  pelvic  cavity  or  placed  at  the  junction  of  the 
latter  with  the  iliac  fossae,  at  the  level  of  the  inlet  of  the  true  pelvis. 

Generally  speaking,  the  ilio-pelvic  glands  are  disposed  fairiy 
regularly  round  the  vessels.  This  paravascular  arrangement 
enables  us  to  divide  them  into  three  large  groups :  namely  the 
external  iliac  glands,  which  run  by  the  side  of  the  vessels  of  this 
name ;  the  hypogastric  glands,  scattered  along  the  trunk  and 
branches  of  the  internal  iliac  artery ;  the  common  iliac  glands 
placed  round  the  vessels  of  the  same  name. 

The  older  writings  only  furnish  us  with  very  incomplete  and  often  incorrect 
ideas  on  the  topography  of  the  glands  of  the  pelvis.  Quite  recently,  Marcille 
arid  one  of  the  authors  have  undertaken  the  study  of  these  glands,  and 
have  given  a  new  classification,  which  we  here  adopt. 

Vide  :  Cuneo  and  Marcille,  Topographic  des  ganglions  ilio-pelviens. 
Comrmmic  Soc.  anat.,  decembre,  1901.  Marcille,  Lymphatiques  et  gan- 
glions ilio-pelviens.  Th.  Paris,  1902. 


130  SPECIAL    STUDY    OF    THE    LYMPHATICS 

1.  The  External  Iliac    Glands.— The    glands    grouped    round   the 
external  iliac    vessels  usually  present    a    constant    arrangement. 
We  may  regard  them  as  forming  three  chains  which  are  more  or  ' 
less  continuous,  viz.  an  external,  a  middle,  and  an  internal  chain.1 

A.     THE  EXTERNAL  CHAIN. — The  external  chain  comprises   three 


hypogastric 
artery 


FIG.  41. — Ileopclvic  glands  (Cuneo  and  Marcille). 

a.  Right  juxta-aortic  gland. — 6.  Gland  of  the  promontory. — c.  Common  iliac  gland, 
(middle  group). — d  and  e.  External  iliac  glands  (external  chain). — /.  Hypogastric  gland. — g. 
External  iliac  gland  (external  chain). — h.  Left  juxta-aortic  gland. — i,  j.  Common  iliac  glands. 
— Jfc.External  iliac  gland  (external  chain). — /,  ra.  External  iliac  glands  (middle  chain). — n. 
Retro-crural  external  gland. — o.  Obturator  gland. 


xTo  thoroughly  grasp  the  topography  of  these  glands  we  must  recall  the 
position  of  the  external  iliac  vessels.  The  artery  and  vein  do  not  lie,  as  is 
too  often  stated,  on  the  psoas  muscle  ;  they  are  clearly  internal  to  it,  and 
lie  on  its  inner  border,  overhanging  the  pelvic  cavity. 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      131 

to  four  glands  which  shew  a  tendency  to  insinuate  themselves 
between  the  internal  border  of  the  psoas,  and  the  external  iliac 
artery.  The  lower  gland  of  this  chain  is  placed  immediately  behind 
the  crural  arch.  It  lies  on  the  terminal  portion  of  the  external 
iliac  artery,  and  covers  the  origin  of  the  deep  circumflex  iliac  and 
the  deep  epigastric  arteries.  It  is  underneath  this  gland,  that  the 
genito-crural  nerve  divides  into  its  two  terminal  branches.  This 
gland  may  be  called  the  external  retro-crural  gland.  It  is  usually 
a  fair  size  ;  sometimes  it  is  replaced  by  two  smaller  glands,  the 
more  internal  of  which  then  represents  the  commencement  of  the 
middle  chain.  The  overlying  glands  are  lodged  in  the  interspace 
which  separates  the  external  iliac  artery  from  the  internal  border 
of  the  psoas. 

B.  MIDDLE    CHAIN. — The   middle    chain  comprises  two  or  three 
glands    placed  on  the  anterior  surface  of  the  external  iliac  vein. 
When   there  are  three  glands,  the  lowest  is  situated   immediately 
behind  the  crural  arch.    We   may  term  it   the  middle  retro-crural 
gland.     It  is  inconstant.    It  is  in  fact   most  usually  fused  with 
the  adjacent  gland  of  the  preceding  chain. — The  middle  gland  is 
usually  situated  midway  between  the  crural  arch  and  the  bifurcation 
of  the  common  iliac  artery. — As  regards  the  superior  gland,  it  is 
placed  immediately  in  front  of  the  origin  of  the  internal  iliac  artery, 
and  is  often  covered  by  the  ureter.      These   two   glands,   i.e.  the 
middle  and  superior  of  the  middle   chain,  sometimes  show  a  ten- 
dency to  become  situated  on  the  internal  surface  of  the  vein,  and 
are  almost  intrapelvic. 

C.  INTERNAL  CHAIN. — The  internal  chain  comprises  three  to  four 
glands  and  is  placed  below  the  external  iliac  vein,  against  the  lateral 
wall  of  the  pelvic  cavity,  above  the  obturator  nerve.       The  inferior 
gland  of  this  chain  is  situated  immediately  behind  the  external  or 
lymphatic  portion  of  the  crural  ring,  and  lies  upon  the  terminal  por- 
tion of  the  ilio-pectineal  line.     It  is  placed  next  to   the  gland  of 
Cloquet,  or  when  this  is  absent,  to  the  chain  of  deep  inguinal  glands. 
It  may  be  styled  the  internal  retro-crural  gland. — The  suprajacent 
gland  (the  middle  gland)  is  remarkable  for  its  size  and  constancy ; 
it  is  elongated  like  a  spindle,  and  situated  on  a  slightly  lower  plane 
than  the  former,  as  though  its  weight  were  dragging  it  down  into 
the  pelvic  cavity.   It  lies  immediately  above  the  obturator  nerve. 
—The  third  gland  (superior  gland)  is  usually  smaller,  and  is  placed 
behind   those   already    mentioned,   in  front    of    the  trunk  of   the 
internal  iliac  artery. 


132          SPECIAL    STUDY    OF    THE    LYMPHATICS 

This  chain  may  be  reduced  to  two  or  even  a  single  gland,  by 
fusion  of  its  constituent  elements,  in  which  case  an  enormous 
elongated  gland  may  be  found  lying  on  the  lateral  wall  of  the 
pelvis;  extending  from  Gimbernat's  ligament  to  the  hypogastric 
artery. 

Most  authors  regard  this  internal  chain  as  belonging  to  the 
group  of  hypogastric  glands,  but  we  think  this  view  has  many 
inconveniences.  Though  prolapsed  into  the  pelvis,  this 
chain  is  obviously  continuous  with  the  deep  inguinal  glands, 
and  remains  a  satellite  of  the  external  iliac  vein.  As  figures 
42  and  43  well  show,  it  forms  an  integral  part  of  the  strong  lym- 
phatic current  which  runs  upwards  from  the  lower  limbs  towards 
the  lumbar  region.  Further,  as  we  shall  see  later  on  (vide  p.  133), 
its  pelvic  affluents  are  relatively  few,  and  are  much  less  impor- 
tant than  its  afferent  femoral  lymphatics. 

Obturator  Gland. — In  the  above-mentioned  chain  may  be  included 
a  small  inconstant  gland  placed  beneath  the  obturator  nerve,  on  the 
actual  level  of  the  internal  surface  of  the  obturator  foramen. 
This  gland,  which  receives  the  deep  lymphatics,  the  satellites  of 
the  obturator  vessels,  is  attached  by  its  efferents  to  the  lower  bor- 
der of  the  large  middle  gland  of  the  internal  chain  (vide  Fig.  41). 
It  is  to  this  gland  that  the  name  of  obturator  should  be  confined. 

This  question  regarding  the  obturator  gland  has  given  rise  to  numerous 
discussions.  It  was  Cruveilhier  who  first  insisted  on  the  existence  of  a 
gland  at  the  level  of  the  internal  orifice  of  the  obturator  foramen.  "  I  shall 
regard  as  constant  a  fair-sized  gland  which  occupies  the  internal  orifice  of 
the  oval  canal  and  which  I  have  frequently  seen  inflamed  or  indurated 
in  maladies  of  the  uterus.  It  may  be  styled  the  gland  of  the  oval  foramen." 
Bouilly,  and  A.  Guerin  admitted  the  existence  of  this  gland,  and  described  its 
afferents  as  coming  from  the  uterus,  and  considered  that  it  played  an 
important  part  in  the  pathogeny  of  certain  varieties  of  phlegmenous 
parametritis.  Sappey,  on  the  contrary,  does  not  mention  any  gland  at 
the  entrance  of  the  obturator  foramen.  As  one  of  the  present  writers 
long  since  observed,  it  is  certain  that  normally  no  gland  exists  at  this 
spot.  The  existence  of  the  little  gland  mentioned  above  must  be  regarded 
as  an  anomaly,  the  frequency  of  whose  presence  it  is  most  difficult  for  us 
to  estimate.  When  this  little  glandular  nodule  is  absent,  the  gland  nearest 
to  the  obturator  foramen  is  our  middle  gland  of  the  internal  chain,  which 
is  situated  about  15  to  20  millimetres  behind  and  above  the  entrance  to 
the  canal.  It  is  to  this  gland  that  Cruveilhier  must  have  alluded.  The 
"  voluminous  and  constant  "  gland  of  which  he  speaks  cannot  be  this 
minute  and  often  absent  gland  which  we  have  just  noted.  It  is  moreover 
important  to  add  at  once  that  the  middle  gland  of  the  internal  chain 
receives  no  lymphatics  coming  from  the  uterus  (vide  Uterine  lymphatics 
pp.  163  and  164). 

BIBLIOGRAPHY.— Cruveilhier,    Anatomie     descriptive,    3e    Edition,    t.    Ill, 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      133 

p.    154.— Guerhi,  Bull,   de  V Ac.   de  med.,    1887,   p.   533.— Cantin.   Des  lym- 
phangites   periuterines   non   puerperales.    Th.    Paris,    1889. — Poirier.    Lym- 
phatiques   des    organes   genitaux    de   la   femine.    Procjres    medical,     1890.— 
Poirier  et  Picque.  Etude  sur  la  hernie  obtura trice.  Revue  de  Chirurgie    1891 
t.  XI,  p.  693. 

AFFERENT  VESSELS. — Each  of  the  three  chains  receives  distinct 
affe  rents. 

1.  External  Chain. — The  majority  of  lymphatics  which  eventually 
terminate  in  the  external  chain,  end  in  the  inferior  gland  of  this 
chain  (the  retro-crural  gland).     The  other  glands  of  the  external 
chain    simply  constitute  a  second   relay   interposed   in  the  course 
of  afferents  of  the  preceding  gland. 

This  external  retro-crural  gland  receives— 

(a)  Some  of  the  efferents  from  the  superficial  and  deep  inguinal 
glands. 

(b)  The  lymphatics  from  the  glans  or  clitoris,  which  come  to  this 
gland  per  the  inguinal  canal. 

(c)  Some  of  the  deep  lymphatics  from  the  sub-umbilical  portion 
of  the  abdominal  wall ;  these  are  satellites  of  the  deep  epigastric 
and  deep  circumflex  iliac  arteries  (vide  p.^151   and  Fig.  50). 

2.  Middle  Chain. — When  the  middle  chain  is  reduced,  as  is  usually 
the  case,  to  two  glands  only,  the  inferior  gland  receives   at   first 
a  double  pedicle  which  comes  to  it  from  the  external  and  internal 
retro-crural  glands  (vide  Fig.  42).    Vessels  from  the  bladder,  pros- 
tate, neck  of  the  uterus,  and  from  the  upper  portion  of  the  vagina 
end  in  this  chain. 

3.  Internal  Chain. — This  chain  receives  numerous  afferents,  which 
may  be  divided  in  the  following  way — 

(a)  Efferent  vessels  from  the  superficial  and  deep  inguinal  glands. 

(b)  Deep   collecting  trunks   from   the    glans  and  clitoris,  which 
pass  via  the  crural  canal. 

(c)  Deep  collecting  trunks  from  the  umbilicus  and  subumbilical 
portion  of  the  abdominal  wall. 

(d)  Lymphatic  satellites  of  the   obturator  vessels  coming  from 
the  adductor  muscles  of  the  thigh. 

(e)  Lymphatics    from   the   neck   of   the    bladder,    the   prostate, 
and  membranous  portion  of  the  urethra. 

(/)  Some  efferents  from  the  hypogastric  glands,  and  more  par- 
ticularly from  the  middle  haemorrhoidal  gland. 

As  we  have  seen,  the  three  external  iliac  chains  receive  lymphatics 
coming  from  the  inguinal  glands.  The  external  and  internal  chains 

I** 


134  SPECIAL    STUDY    OF    THE    LYMPHATICS 

receive  these  vessels  directly  ;  the  middle  chain  only  receives 
them  after  they  have  been  interrupted  in  the  external  and  inter- 
nal retro-crural  glands.  It  seems  that  the  strong  lymphatic 
current,  which  has  its  source  in  the  lower  limb,  divides,  in 
the  region  of  the  external  iliac  vessels  into  three  secondary  currents, 
corresponding  to  each  of  our  three  glandular  chains. 

On  the  other  hand,  the  middle  and  internal  chains  are  the 
only  ones  to  receive  lymphatics  coming  from  the  true  pelvis.  We 
may  be  surprised  at  this  arrangement,  whereby  the  middle  chain, 
placed  at  the  level  of  the  inlet,  receives  lymphatics  from  the 
pelvic  cavity  and  also  from  the  prostate  or  vagina.  The  fact 
is,  that  these  vessels  have  a  somewhat  long  course  to  pursue 
before  arriving  at  the  middle  chain,  and  it  may  appear  singular 
Miat  they  are  not  arrested  in  the  internal  chain,  which  they  are 
compelled  to  cross.  Their  termination  in  the  middle  chain  is  ex- 
plained by  their  development.  In  the  foetus,  as  is  well  known,  the 
prostate  and  vagina  occupy  a  much  higher  position  than  in  the 
adult,  and  are  placed  at  the  actual  level  of  the  inlet.  Their 
lymphatics  have  therefore  only  a  very  short  course  to  pursue 
before  reaching  the  middle  chain.  Later  on.  when  these  organs 
sink  into  the  pelvic  cavity,  these  vessels  secondarilv  acquire  a 
longer  and  more  complicated  course.  We  shall  see  an  analogous 
but  much  more  striking  phenomenon  manifest  itself  in  the 
lymphatics  of  the  ovary  and  testicle. 

EFFERENT  VESSELS. — Each  gland  belonging  to  these  different  chains 
sends  its  efferents  to  the  gland  above  it,  so  that  the  highest  gland  of 
the  chain  continues  the  lymphatic  circulation  of  those  placed  below  it. 

The  efferents  of  the  superior  gland  of  the  external  chain  terminate 
in  the  inferior  gland  of  the  external  group  of  the  common  iliac 
glands.  The  efferents  of  the  superior  gland  of  the  middle  chain  are 
divided  into  two  groups:  the  external  and  the  internal;  the  first, 
which  is  the  most  important,  joins  with  the  efferents  of  the  external 
chain ;  the  second  joins  the  efferents  of  the  internal  chain. 

The  efferents  of  the  internal  chain  are  placed  beneath  the  trunk 
of  the  internal  iliac  artery,  and  become  united  to  the  efferents  of  the 
hypogastric  glands,  and  eventually  terminate,  like  the  latter,  in  the 
middle  group  of  the  common  iliac  glands  (the  group  placed  in  the 
fossa  for  the  lumbo-sacral  nerve). 

Epigastric  and  Circumflex  Iliac  Chain.— Two  secondary  chains 
should  be  included  with  the  external  iliac  glands,  viz.  the  deep 
epigastric  and  deep  circumflex  iliac  chains. 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      135 

The  epigastric  chain  comprises  three  to  six  little  glands  placed  over 
the  course  of  the  lower  third  of  the  deep  epigastric  artery.  These 
glands,  the  size  and  number  of  which  is  very  variable,  may  be 
wanting. 

The  circumflex  iliac  chain  comprises  two  to  four  little  glands  placed 
over  the  artery  of  this  name.  They  are  even  smaller  than  those 
of  the  preceding  group,  and  are  very  frequently  absent. 

2.  The  Internal  Iliac  or  Hypogastric  Glands. — The  hypogas- 
tric  glands  are  connected  to  the  branches  of  the  artery  of  this 
name.  Their  number  is  somewhat  variable.  They  are  placed 


12  — 


FIG.  42.—  Scheme  of  the  ileo-pelvic  glands  (Cunco  and  Mamllc). 

1  and   1  bis. Inferior  glands  of  right  and  left  lateral-nortic  groups. — 2.  Common  iliac 

group  (external  group). — 3.  Middle  band  of  external  chain  of  external  iliac  glands.— 4.  Retn>- 
crural  external  glar.d.- — 5.  Gland  of  the  middle  ch«in  of  external  iliac  glands. — C.~Glo,nd  in 
fossa  for  the  lumbo-sacral  nerve.— 7  and  7  bis.  Group  of  the  promontory;  on  th*  right, 
the  gland  is  beneath  the  left  common  iliac  vein  ;  on  the  left,  one  of  the  glands  is  in  front  of 
the  same  vein. — 8.  Lateral  sacral  group. — 9.  Hypogastric  group.— 10.  Gland  of  the  internal 
chain  of  external  iliac  glands. — 11.  Retro-crural  internal  gland. — 12.  Deep  inguinal  gland. 
—  13  and  14.  Superficial  inguinal  glands. 

near  the  origin  of  the  different  branches  of  the  internal  iliac  artery, 
in  the  angles  formed  by  their  separation.  The  most  anterior 
of  these  glands  is  placed  between  the  hypogastric  (umbilical) 
and  the  subjacent  artery,  which  is  usually  the  obturator.  The 
most  posterior  is  placed  on  the  trunk  of  the  gluteal  artery.  The 
others  are  placed  between  the  two  preceding  and  unite  them., 
describing  a  fairly  regular  curve,  the  concavity  of  which  points 
upwards  and  forwards.  The  arrangement  of  these  intermediary 


136 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


glands    is    somewhat    inconstant.       However    they   are    generally 
arranged  as  follows— 

The  first  is  placed  in  the  neighbourhood  of  the  uterine  or  pros- 
tatic  artery  ;  the  second,  which  is  more  posterior,  rests  on  the 
common  trunk  of  the  sciatic  and  pudic  ;  a  third,  placed  apart 
from  the  preceding,  is  situated  oh  the  middle  haemorrhoidal 
artery  ;  it  usually  corresponds  to  the  point  at  which  this  artery 
breaks  up  into  its  terminal  branches,  and  is  nearly  in  contact  with 


FIG.  43.— Ileo-pelvic  glands  (lateral  view)  (Cuneo  and  Marcille). 

a  and  6.  External  iliac  glands  (middle  chain).— c.  External  iliac  gland  (external  chain). 
d.  Retro-crural  external  gland.— e.  Retro-crural  internal  gland.—/,  g.  Lymphatics  of  the 
bladder. — h.  Collecting  trunks  from  the  mucus  membrane  of  the  glans  passing  through  the 
inguinal  canal.— i.  Praesymphysinl  glandular  nodule.—/.  Gland  of  the  promontory  — 

o  T?"1361™  glutCal  «land'— L  Latcral  sa"'«l  gland.— m,  r..  Hypogastric  glands.— 
o.  Satellite  trunk  of  internal  pudic  vessels.— p.  Middle  haemorrhoidal  trunk.—  q,  r.  Prostatic 
collecting  trunks. — s.  Urethral  collecting  trunks. 

the  lateral  wall  of  the  rectum  (middle  haemorrhoidal  gland).  There 
is  one  more  group,  even  more  isolated,  which  is  formed  by  two  or 
three  glands  situated  internal  to  the  second  or  third  sacral  foramina, 
and  on  the  course  of  the  lateral  sacral  artery  (lateral  sacral  gland).' 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN     137 

All  these  glands  rest  on  the  inner  surface  of  the  pelvic  fascia,  and 
to  show  them,  we  need  merely  raise  the  peritoneum.  Sometimes 
they  are  placed  on  the  external  surface  of  this  aponeurotic  layer,  as 
may  be  seen  when  the  latter  is  dissected  off  from  the  lateral  wall  of 
the  pelvis.  All  these  glands  are  united  to  each  other  by  numerous 
anastomoses. 

AFFERENT  VESSELS. — The  hypogastric  glands  receive  afferents 
from  all  the  pelvic  viscera.  We  may  thus  see,  ending  in  this 
glandular  group,  lymphatics  from  the  membranous  and  prostatic 
portions  of  the  urethra,  prostate,  bladder,  vesiculae  seminales, 
vasa  deferenti a,  vagina,  uterus,  and  rectum.  All  these  vessels  are 
more  or  less  satellites  of  the  branches  to  the  different  viscera,  given 
off  by  the  internal  iliac  artery. 

They  also  receive  the  collecting  trunks  of  the  sub-aponeurotic 
portions  of  the  perineum,  the  lymphatics  from  the  penile  portion 
of  the  urethra,  and,  according  to  the  researches  of  Marcille,  even 
certain  trunks  from  the  anus.  These  vessels  follow  the  course 
of  the  internal  pudic  artery  and  its  branches. 

Finally,  the  deep  lymphatics  from  the  posterior  surface  of  the 
thigh  and  gluteal  region,  satellites  of  the  sciatic  and  gluten] 
vessels  may  be  seen  to  terminate  in  these  glands. 

EFFERENT  VESSELS. — The  efferents  of  the  hypogastric  glands 
are  directed  upwards  and  outwards,  and  passing  underneath  the 
common  iliac  vein,  terminate  in  the  middle  group  of  the  common 
iliac  glands.  We  shall  see  later  on  that  this  group,  which  is  situ- 
ated underneath  the  vessels,  in  the  fossa  for  the  lumbo-sacral 
nerve,  itself  sends  its  efferents  to  the  inferior  part  of  the  lateral 
aortic  chain  of  the  corresponding  side. 

3.  The  Common  Iliac  Glands.  -  The  glands  grouped  around  the 
common  iliac  artery  may  be  divided  into  three  groups,  viz.  an 
external,  a  middle,  and  an  internal. 

The  external  group  generally  comprises  two  glands,  which  are 
placed  external  to  the  artery  and  which  lie  on  the  internal  border 
of  the  psoas.  This  group  is  continuous  with  the  external  chain  of  the 
external  iliac  glands,  and  is  continuous  above  without  any  line  of 
demarcation  with  the  juxta-aortic  group  of  the  corresponding  side. 

The  middle  group  (deep  or  retro- vascular)  is  made  up  of  two  to  four 
glands,  which  are  entirely  hidden  behind  the  vessels.  These  glands 
occupy  a  fossa  which  has  recently  been  well  described  by  Marcille, 
and  which  is  constituted  as  follows  :  Internally,  it  is  limited  by  the 
body  of  the  5th  lumbar  vertebra  ;  externally,  by  the  internal  border 


138  SPECIAL    STUDY    OF    THE    LYMPHATICS 

of  the  psoas.  Its  base  is  formed  by  the  upper  border  of  the  wing 
of  the  sacrum.  This  fossa  is  covered  by  the  common  iliac  vessels, 
which  tend  to  sink  down  within  it.  It  is  in  the  fat  which  fills  this 
fossa,  above  the  lumbo-sacral  and  obturator  nerves  which  occupy 
its  base,  that  we  find  the  retro- vascular  glands. 

The  internal  group,  with  that  on  the  opposite  side,  constitutes 
an  uneven  and  mesially  placed  group  in  front  of  the  body  of  the 
5th  lumbar,  or  on  the  disc  between  this  and  the  sacrum.  We 
may  call  it  the  group  of  the  promontory.  It  is  sometimes  formed 
of  two  fairly  distinct  masses  :  one,  the  inferior  and  on  the  right 
side,  lies  underneath  the  left  common  iliac  vein  (subvenous  collec- 
tion) ;  the  other,  the  superior  and  on  the  left,  lies  on  this  vein 
(prae venous  collection),  vide  Figs.  41  and  43. 

AFFERENT  VESSELS. — The  external  and  the  middle  groups  of  the 
common  iliac  glands  do  not  really  receive  any  vessels  ema- 
nating directly  from  the  neighbouring  organs.  On  the  contrary, 
they  form  the  terminus  for  the  numerous  and  large  efferents  of  the 
three  external  iliac  chains  and  of  the  hypogastric  glands. 

The  internal  group  or  group  of  the  promontory,  receives  (1)  certain 
efferents  from  the  lumbo-sa'cral  group ;  (2)  vessels  coming  from 
the  majority  of  the  pelvic  organs  ;  in  fact,  the  lymphatics  from 
the  prostate,  neck  of  the  bladder,  neck  of  the  uterus,  vagina,  and 
perhaps  also  from  the  rectum,  terminate  in  this  group.  The  collect- 
ing trunks  of  the  right  side  end  in  the  subvenous  glands,  those 
on  the  left  in  the  praevenous  glands.  All  these  vessels  clearlv 
take  the  same  course  (vide  Figs.  55,  58,  68).  At  their  commence- 
ment they  are  attached  to  the  pelvic  floor,  they  then  ascend  into 
the  concavity  of  the  sacrum,  and  passing  slightly  external  to  the 
middle  line,  reach  the  gland  of  the  promontory,  after  pursuing  a 
long  course  which  on  the  whole  describes  a  fairly  regular  curve. 

EFFERENT  VESSELS.— The  efferents  of  the  three  common  iliac 
groups  converge  towards  the  inferior  part  of  the  lateral  aortic  chain 
of  the  corresponding  side. 

All  the  ilio-pelvic  lymphatics  finally  end  therefore  in  the  two  right 
and  left  juxta-aortic  chains.  The  inferior  gland  of  these  two  chains 
represents  the  point  of  convergence  of  all  the  efferents  of  the 
glandular  groups  which  we  have  just  been  studying.  On  the  one 
hand,  it  receives  the  efferents  of  the  external  group  of  the  common 
iliac  glands  which  itself  comprises  the  internal  and  middle  chains 
of  the  external  iliac  glands.  On  the  other  hand,  it  receives  the 
efferents  of  the  group  of  the  promontory,  and  the  glands  in  the 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      139 


lumbo-sacral  fossa;  and,  as  we  have  already  seen,  the  latter  is  the 
terminus  of  the  afferent  vessels  of  the  hypogastric  glands  and  of 
the  internal  chain  of  the  external  iliac  glands.  There  is  then,  in 
the  lower  portion  of  the  lumbar  region,  a  simplification  of  the 
lymphatic  channels ;  they  are  reduced  to  two  large  lateral  ascend- 
ing currents  ;  from  this  point  it  is  true,  we  shall  see  a  new 
current,  uneven  and  median,  making  its  appearance,  the  origin  of 
which  is  entirely  different,  inasmuch  as  it  conveys  the  lymph  from 
the  intestinal  portion  of  the  digestive  canal. 

2. — ABDOMINO-AORTIC  GLANDS 

•     The  abdomino-aortic  glands,  which  number  from  twenty  to  thirty, 

are  grouped  around  the  abdominal  aorta.     Basing  our  classification 

on  their  relations 

to      this 

trunk, 

divide 


Intffititif 


Prce-aortic  g land. 

'    •••••  Left  juxta-aortic  gland. 

—  Right     ji'.rt'i-'">rfic   praevenoits 
Renal  gland. 

Retro-aortic  gland. 

Right     juxta-aoriic   retrovenous 
gland. 


.  Inf.  cava. 


arterial 
we  may 
them  into 
four  groups  :  (1) 
The  left  juxta- 
aortic  glands; '(2)  Aorla 
The  right  juxta- 
aortic  glands ;  (3) 
The  prae  -  aortic 
glands;  (4)  The 
retro  -  aortic 
glands. 

Each  of  these 
groups  possesses  a 
special  lymphatic 

territory."  The  juxta-aortic  glands  receive  the  efferents  of  the 
common  iliac  glands,  as  well  as  the  parietal  lymphatics,  and  the 
lymphatics  of  the  kidneys  and  genital  glands.  In  the  prae-aortic 
glands,  the  lymphatics  from  the  digestive  canal  and  its  accessories 
more  especially  terminate.  As  regards  the  retro-aortic  glands,  they 
receive  but  few  vessels  coming  directly  from  the  abdominal  vis- 
cera •  they  constitute  a  fresh  relay  interposed  in  the  course  of 
certain  efferent  vessels  of  the  preceding  groups,  before 
vessels  join  the  thoracic  duct. 

1  Left  Juxta-aortic  Glands.— The  left  juxta-aortic  glands  form 
an  almost  continuous  vertical  chain,  which  runs  along  the  left 
flank  of  the  abdominal  aorta.  This  chain  reposes  on  the  vertebral 


pIG.  44.  —  Transverse  section 
(diagrammatic)  showing  the 
general  arrangement  of  the 
abdomino-aortic  glands. 


140 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


attachments  of  the  psoas  muscle  and  on  the  left  pillar  of  the  dia- 
phragm ;  it  is  crossed  on  its  anterior  surface  by  the  left  renal  artery 
and  vein. 

Afferent  Vessels. — These  glands  receive  :  (1)  the  efferent  lym- 
phatics of  the  common  iliac  glands  ;  (2)  the  satellite  lymphatics  of 
the  lumbar  arteries,  which  come  from  the  large  abdominal  muscles  ; 


7  _. 


FIG.  45.— Abdomino-aortic  glands  in  the  new-born  infant  (after  Cuneo). 

1.  Left  supra -renal  capsule.— 2.  Left  spermatic  vein. — 3.  Left  juxta-aortic  gland.— 4. 
Inferior  mesenteric.— 5.  Hypogastric  artery— 6.  Rectum. — 7.  Inferior  phrenic  artery.— 8. 
Superior  mesenteric  artery.— 9.  Right  juxta-aortic  gland.— 10.  Ureter.— 11.  The  posterior 
gland  of  the  middle  chain  of  the  external  iliac  group. 

(3)  the  lymphatics  from  the  left  testicle  in  the  male,  from  the  left 
annexa  and  corresponding  half  of  the  body  the  uterus  in  the 
female  ;  (4)  the  lymphatics  of  the  kidney  and  the  left  supra-renal 
capsule. 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      141 

Efferent  Vessels. — The  efferent  vessels  of  the  left  juxta-aortic 
glands  may  be  divided  into  four  groups.  Some  of  them  empty 
their  contents  into  the  prae-aortic  glands  ;  others  end  in  the  retro- 
aortic  glands  ;  while  others,  more  numerous,  unite  into  a  common 
trunk  which  ends  in  the  receptaculum  chyli  ;  others  finally,  traverse 
the  left  pillar  of  the  diaphragm  and  empty  their  contents  into  the 
thoracic  duct  a  little  above  its  origin  (vide  fig.  114).  Some  of 
these  vessels  are  sometimes  interrupted  by  glands  placed  between 
the  posterior  surface  of  the  pillar  of  the  diaphragm  and  the  vertebral 
column. 

2.  Right  Juxta-aortic  Glands. — The  right  juxta-aortic  glands  are 
placed — some  in  front  of  the   inferior   vena  cava,  others   behind 
it.     There  is  a  sort  of  adjustment  between  these  two  groups,  so  that 
when  one  of  them  is  well  developed,  the  other  is,  generally,  sensibly 
reduced. 

The  prae-venous  glands,  from  3  to  6  in  number,  are  usually 
found  underneath  the  junction  of  the  renal  veins  with  the  inferior 
vena  cava.  The  retro-venous  glands  rest,  as  do  the  left  juxta-aortic 
glands,  on  the  origins  of  the  psoas  muscle  and  on  the  anterior  surface 
of  the  corresponding  pillar  of  the  diaphragm. 

Afferent  Vessels. — The  right  juxta-aortic  glands  receive  the  same 
affluents  as  the  homologous  group  of  the  other  side.  It  is 
interesting  to  note  that  the  genital  lymphatics  especially  pass  to 
the  prae-venous  glands,  and  the  parietal  lymphatics  to  the  retro- 
venous  glands.  As  regards  the  lymphatics  of  the  kidney,  they  are 
divided  between  the  two  groups,  as  we  shall  see  later  on. 

Efferent  Vessels.— The  efferents  of  the  right  juxta-aortic  glands 
terminate  in  the  same  way  as  the  juxta-aortic  glands  of  the  opposite 
side. 

3.  Prae-aortic  Glands.— These  glands  sometimes  form,  at  least  in 
the  new-born  infant,  a  continuous  chain  situated  on  the  anterior 
surface  of  the  aorta  ;  but  most  frequently  they  are  grouped  into 
three  distinct  masses,  viz.  an  inferior,  middle,  and  superior,  placed 
on  the  origin  of  the  three  large  trunks  which  the  aorta  sends  to  the 
abdominal  portion  of  the  digestive  canal. 

(a)  The  inferior  mass  is  usually  formed  by  two  glands,  which  are 
elongated  vertically  and  symmetrically  placed  on  either  side  of  the 
origin  of  the  inferior  mesenteric  artery.  In  these  glands  terminate 
the  lymphatics  from  the  rectum,  ileo-pelvic  colon,  and  the 
ascending  colon.  These  vessels,  as  we  shall  see  later  on  (p.  191) 
have  moreover  already  traversed  one  or  two  glandular  relays. 


142  SPECIAL    STUDY    OF    THE    LYMPHATICS 

(b)  The  middle  mass  is  made  up  of  a  large  collection  of  glands  sur- 
rounding the  origin   of  the  superior  mesenteric  artery,  and   con- 
tinuous without  line  of  demarcation  with  the  glands  placed  at  the 
root  of  the  mesentery.     This  mass  receives  the  lymphatics  coming 
from  the  small  intestine,  coecum,  appendix,  ascending  colon,  trans- 
verse colon,  and  pancreas. 

(c)  The  superior  mass  is  formed  by  one  to  three  glands  placed 
above  the  coeliac  trunk.     It  is  continuous  without  line  of  demarca- 
tion with  the  three  chains  :  hepatic,  coronary,  and  splenic,  which 
are,  so  to  speak,  outward  prolongations  from  it. 

Afferent  Vessels. — The  prae-aortic  glands  receive  certain  efferents 
from  the  juxta-aortic  group  ;  but  almost  all  their  afferents  are 
formed  by  vessels  coming  from  the  glandular  groups,  in  connection 
with  the  mesenteric  arteries  or  the  coeliac  trunk,  and  which  receive 
the  lymphatics  of  the  intestine,  the  stomach,  the  liver,  the  pancreas, 
and  the  spleen. 

Efferent  Vessels. — The  three  prae-aortic  glandular  masses  are 
joined  together  by  numerous  vessels.  The  efferent  trunks  to  which 
these  glands  give  origin  turn  round  the  lateral  parts  of  the  abdo- 
minal aorta.  Their  mode  of  termination  varies  at  different  levels. 
The  inferior  terminate  in  the  retro-aortic  glands  subjacent  to 
the  receptaculum  chyli.  The  superior  end  in  this  receptaculum. 
Though  they  sometimes  terminate  separately  into  the  latter,  they 
most  commonly  unite  into  a  common  trunk  (truncus  intestinalis), 
which  runs  side  by  side  with  the  common  trunk  formed  by  the 
efferents  of  the  left  juxta-aortic  group,  and  which  simultaneously 
with  the  latter  empties  its  contents  into  the  receptaculum  chyli. 

In  the  prae-aortic  group  may  be  included  all  the  glands  placed 
on  the  various  branches  given  off  by  the  abdominal  aorta  to  the 
subdiaphragmatic  portion  of  the  digestive  canal.  We  shall  there- 
fore have  to  study — 

(1)  The  glands  situated  in  the  course  of  the  two  mesenteric  arteries. 

(2)  The  glands  attached  to  the  branches  of  the  coeliac  axis. 
(1)  THE  GLANDS  ATTACHED  TO  THE  MESENTERIC  ARTERIES. — The 

glands  attached  to  the  two  mesenteric  arteries  seem  at  first  sight 
to  be  irregularly  scattered  over  the  course  of  these  arteries  and 
their  branches :  their  general  arrangement  however  is  sufficiently 
definite  to  enable  us  to  attempt  its  classification. 

Some  of  these  glands  are  placed  beneath  the  last  series  of  arches 
which  the  arterial  branches  destined  for  a  given  segment  of  intestine 
form  by  their  anastomosis.  These  glands,  thus  attached  to  the 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      143 


terminal  arterioles,  are  very  close  to  the  intestinal  insertion  of 
the  mesentery,  and  we  may  call  them  the  juxta-intestinal  glands. 
Nearly  always  of  small  size,  they  rarely  retain  artificial  injections, 
and  in  the  case  of  cancers  only  arrest  the  neoplasmic  elements  for 
a  short  time.  They  are  therefore  comparable  to  those  small  glands 
which  we  have  already  had  occasion  to  notice  on  the  course  of 
the  lymphatics  of  the  various  organs,  which  the  Germans  call 
"  Schaltdriisen  "  (vide  p.  86).  These  glands  present  no  mor- 
phological fixity,  and  their  number  varies  considerably  in  different 
subjects. 

Other  glands,  which  are  larger  and  more  constant  in  their  presence 


ffc:>,,  -¥. 

itffSn.^ 


.-3 


FIG.  46.— Glands  of  the  small  curvature  and  the  subpyloric  glands  in  the  new-born 
infant. 

1.  Praecardiac  glands.— 2.  Glands  of  the  small  curvature.— 3.  Subpyloric  glands. 

and  situation,  are  placed  in  the  course  of  the  primary  branches  of 
the  mesenteric  arteries.  They  constitute  the  true  regional  glands 
of  a  definite  segment  of  intestine. 

Others,  finally,  are  placed  round  the  principal  trunks  of  these 
vessels.  They  represent  the  glandular  centres,  which  are  usually 
common  to  many  segments  of  the  intestine.  They  receive  the 
efferents  from  the  preceding  glands. 

For  the  present  we  will  rest  content  with  these  general  data,  and 
to  avoid  useless  repetitions,  we  will  study  the  exact  topography  of 


144  SPECIAL    STUDY    OF    THE    LYMPHATICS 

these  glands  when  we  deal  with  the  lymphatics    of   the  different 
intestinal  segments  with  which  they  are  connected. 

(2)  GLANDS  CONNECTED  WITH  THE  BRANCHES  OF  THE  COELTAC  Axis. 

The  glands  connected  with  the  branches  of  the  coeliac  axis  are 

arranged  in  three  chains  :  viz.  the  coronary  or  gastric,  the  splenic, 
and  the  hepatic.    In  the  latter  we  shall  include  the  bile  duct  chain. 

(1)  THE  CORONARY  OR  GASTRIC. — The  glands  of  the  coronary  chain 
may  be  divided  into  two  groups  :    the  group  of  the  falx  of  the 
coronary  artery,  and  the  group  of  the  small  curvature. 

(A)  The  group  of  the  falx  is  formed   by  glands  situated  by  the 
side  of  the  artery  as  it  runs  in  the  gastro-pancreatic  ligament.    They 
vary  from  two  to  six  in  number.      They  are  never  entirely  absent. 

(B)  Under  the  term  of  group  of  the  small  curvature,  we  will  in- 
clude all  those  glands  which  are  placed  either  on  the  trunk  of  or 
on  the  branches  of  the  coronary  artery  after  the  latter  has  reached 
the  stomach.     These  glands  form  two  principal  masses. 

(a)  Some  accompany  the  left  or  ascending  branches  of  the  artery. 
They  form  a  primary  mass,  which  corresponds  to  the  vertical 
portion  of  the  small  curvature,  and  to  the  gastric  insertion  of  the 
thickened  portion  of  the  gastro-hepatic  omentum. 

With  these  glands  we  may  include  two  smaller  masses,  placed  one  on  the 
anterior  surface,  and  the  other  on  the  posterior  surface  of  the  cardia. 
These  two  masses — the  prae-  and  retro-cardiac — are  sometimes  joined,  accord- 
ing to  Sappey,  by  a  gland  placed  on  the  left  of  the  cardia.  This  left  juxta- 
cardiac  gland  is,  however,  generally  absent. 

(6)  The  secondary  mass  is  formed  by  glands  placed  on  the  course 
of  the  large  right  or  descending  branches  of  the  gastric  artery. 
These  are  usually  grouped  near  the  spot  where  the  coronary  ap- 
proaches the  border  of  the  stomach.  It  is  very  rare  to  meet  any 
of  them  in  that  part  of  the  small  curvature  which  corresponds  to 
the  pylorus  and  the  pyloric  vestibule.  All  these  glands  are  placed 
between  the  two  layers  of  the  small  omentum,  in  the  midst  of  the 
dense  network  formed  by  the  interlacing  of  branches  of  the  coronary 
artery  and  the  left  pneumogastric  nerve. 

The  coronary  gastric  glands  receive  as  afferents  the  lymphatics 
coming  from  the  stomach,  As  we  shall  see  later  on,  their  region 
is  very  extensive  and  constitutes  the  most  important  of  the  various 
lymphatic  territories  of  the  stomach.  Their  efferent  vessels  ter- 
minate in  the  prae-aortic  glands  which  surround  the  coeliac  axis. 

(2)  SPLENIC  CHAIN.— The  splenic  chain  comprises  a  very  variable 
number  of  glands  (four  to  ten),  which  accompany  the  artery  of  this 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      145 

name.  Like  the  artery,  they  are  situated  on  the  posterior  surface, 
and  near  the  superior  border  of  the  pancreas. 

The  extremity  of  this  glandular  chain  is  contained  in  the  pan- 
creatico-splenic  omentum. 

The    afferent    vessels    of    these   glands   come  from    the     spleen, 


FIG.  47. — General  view  of  the  porastomachic  glands  in  the-  new-born  infant. 

The  stomach  has  been  cut  in  the  middle,  and  the  two  halves  have  been  drawn  aside — one 
to  the  right,  and  the  other  to  the  left,  to  show  the  origin  of  the  coeliac  axis.  The  liver  is 
raised,  and  the  transverse  colon  drawn  well  downwards  and  forwards, 

— 1.  Glandular  group  of  the  coeliac  axis. — 2.  Splenic  chain. — 3.  Group  of  the  falx  of  the 
coronary  artery. — 4.  Retro-pyloric  group. — 5.  Sub-epipyloric  group. — 6.  Glands  of  small 
curvature. — 7.  Mesccoiic  glands. — 8.  Glands  at  the  root  of  the  mesocolon,  seen  through 
the  mesocolon. — 9.  Gland  of  the  liiium  of  the  iiver. — 10.  Middie  colic  artery. — li.  Umbiiicai 
vein. — 12.  Pyloric  vessels. — 13.  Right  gastro-epiploic  vein  passing  into  the  middle  colic 
vein.  *,  Point  at  which  the  gastroduoclenal  artery  should  bo  tied  when  the  retropyloric 
glands  are  extirpated. 


the  pancreas   and  fundus  of   the  stomach.       The   efferent    vessels 
terminate  in  the  glands  which  are  placed  on  the  coeliac  axis. 

(3)  THE  HEPATIC  CHAIN. — The  hepatic  chain  comprises  three  to  six 
glands  which  are  situated  in  the  course  of  the  hepatic  artery. 
Some  of  these  glands  are  placed  on  the  horizontal  part  of  this  vessel, 
and  consequently  correspond  to  the  superior  border  of  the  pancreas 
and  to  the  floor  of  the  foramen  of  Winslow.  Others  are  situated  on 
the  vertical  portion  of  the  artery,  and  correspond  with  the  left  side  of 
the  portal  vein.  These  glands  receive  the  lymphatics  of  the  liver  and 

K 


146          SPECIAL    STUDY    OF    THE    LYMPHATICS 

send  out  efferents  which  terminate  in  the  glands  which  surround 

the  origin  of  the  coronary  trunk. 

The  hepatic  chain  gives  off  a  secondary  chain  which  is  a  satellite 
of  the  right  gastro-epiploic  artery.  This  gastro-epiploic  chain 
comprises  two  distinct  glandular  groups,  viz.,  the  subpyloric  and 
retropyloric  group. 

(A)  The  subpyloric  group  on  an  average  comprises  three  to  six  glands, 
which  are  placed  between  the  layers  of  the  great  omentum,  beneath 
the  pyloric  zone  of  the  stomach.     It  is  rare  to  find  glands  in  the 
middle  portion  of  the  great  curvature,  and  quite  exceptional  to  meet 
with  them  in  the  region  of  the  fundus.    The  relation  of  these  glands 
to  the  gastro-epiploic  vessels  is  somewhat  variable  ;  usually  they  are 
subjacent ;  in  some  cases,  however,  they  may  be  placed  between  the 
vessels  and  the  stomach ;  but  it  is  exceptional  to  see  them  in  close 
contact  with  the  stomach,  as  is  the  case  with  the  glands  of  the  small 
curvature.     Thus,  in  cases  of  cancer  they  are  not  blended  with  the 
growth  in  the  pylorus  until  a  well  marked  invasion  of  the  great  omen- 
tum has  taken  place. 

In  the  subpyloric  group  may  be  included  some  aberrant  glands,  which  are 
placed  between  the  layers  of  the  great  omentum,  along  the  descending 
branches  of  the  gastro-epiploic  arch.  These  glands,  which  are  as  variable  in 
number  as  in  arrangement,  may  be  more  than  5  to  6  centimetres  distant  from 
the  great  curvature.  We  can  well  understand  how  they  may  escape  notice  and 
be  left  in  situ,  during  a  gastrectomy,  unless  their  increase  in  size  renders 
them  apparent. 

The  subpyloric  glands  receive  as  afferents  the  lymphatics  coming 
from  the  inferior  region  of  the  stomach  (vide  pp.  197,  198  and  Fig. 
73),  or  the  upper  part  of  the  great  omentum.  Their  efferent 
vessels  follow  the  course  of  the  right  gastro-epiploic  artery  and  ter- 
minate in  the  retro-pyloric  glands,  but  we  may  often  see  one  or 
more  of  these  efferents  end  in  the  glands  which  surround  the  superior 
mesenteric  vessels,  where  the  latter  cross  the  third  portion 
of  the  duodenum.  These  collecting  trunks  then  follow  the  right 
gastro-epiploic  vein,  which,  as  we  know,  frequently  joins  the  sub- 
pancreatic  portion  of  the  superior  mesenteric,  either  directly,  or  by  a 
trunk  common  to  it  and  the  middle  colic  vein  (vide  Fig.  47). 

(B)  The  retro-pyloric  group  usually  comprise  two  to  three  glands 
which  are  continuous  with  the  preceding,  and  are  also  continuous,  with- 
out any  line  of  demarcation,  with  the  glands  of  the  principal  hepatic 
chain.    These  glands,  placed  round  the  trunk  of  the  gastro-duodenal. 
are  in  relation  in  front  with  the  posterior  surface  of  the  pylorus,  and 
behind  with  the  pancreas.    When  they  are  degenerated  they  may  be 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      147 


firmly  adherent  to  this  organ  from  which  it  is  difficult  to  separate 
them.     This  glandular  group  in  not  uncommonly  absent. 

The  retro-pyloric  glands  receive  as  afferents  the  trunks  coming 
from  the  sub-pyloric  group,  some  of  the  lymphatics  coining  from  the 
posterior  surface  and  superior  border  of  the  pylorus,  and  also  the 
trunks  coming  from  the  first  portion  of  the  duodenum. 

THE  GLANDULAR  CHAIN  OF  THE  CYSTIC  AND  COMMON  BILE  DUCT. 111 

the  course  of  the  extra  hepatic  biliary  ducts,  we  find  a  series  of  glands 
which  are  arranged  vertically  and  whose  direction   is  parallel  to 


Gland  of  the  hepatic  cl.ain. 


Hepatic  artery. 


Splenic  vein. 


Superior  m'senteric  glcnd. 


Glun'ljol  common~b\le  duct; 
Client  r>f  common  bile  d'tct. 
Gastro-duoien'd  artery. 

Retro-pancreatic  gland. 
Port  it  vein. 


_ . ftstro-pancreatic  gland. 


.  _  _  .   R"tro-pancr2«tic  gland. 


Fio.  48. — Posterior  surface  of  duodenum  and  pancreas. 

In  this  figure  may  be  seen  the  glands  of  the  hepatic  artery,  the  cystic  and  common  bile 
duct   chains,  and  those  corresponding  to  the  vascular  arch  behind  the  pancreas. 

that  of  these  ducts.  The  highest  of  these  is  none  other  than  the 
cystic  gland  ;  it  is  found  in  the  angle  which  is  open  on  the  left,  and 
which  in  front  is  bounded  by  the  neck  and  body  of  the  gall  bladder. 
This  gland  which  was  pointed  out  by  Mascagni,  and  since  found 
again  by  Broca,  is  inconstant.  The  subjacent  glands  are  arranged 
below  one  another  along  the  course  of  the  cystic  and  common  bile 


148          SPECIAL    STUDY    OF    THE    LYMPHATICS 

ducts,  and  are  placed  along  the  right-hand  border  or  posterior 
surface  of  these  ducts. 

Their  number  and  exact  arrangement  has  appeared  to  us  to  be 
somewhat  variable.  There  is,  however,  one  gland  which  is  fairly 
constant,  namely,  that  placed  at  the  junction  of  the  cystic  and 
hepatic  duct  (Quenu).  Inferiorly,  this  chain  blends  with  the  satellite 
chain  of  the  vascular  arch  behind  the  pancreas. 

It  may  be  seen  therefore  that  in  the  hepatic  pedicle  there  are  two 
chains  relatively  distinct,  one  of  which  is  a  satellite  of  the  two  large 
biliary  collecting  ducts,  while  the  other  follows  the  course  of  the 
hepatic  artery.  Though  this  arrangement  is  not  always  met  with, 
we  think  nevertheless  it  should  be  regarded  as  the  usual  type. 

(4.)  The  Retro-aortic  Glands. — The  arrangement  of  the  retro- 
aortic  glands  is  much  more  variable  than  that  of  the  preceding 
groups.  From  four  to  five  in  number  they  are  placed  in  front  of  the 
3rd  and  4th  lumbar  vertebrae,  immediately  underneath  the  recepta- 
culum  chyli.  Sometimes,  (six  out  of  sixteen  times)  some  small  glands 
placed  between  the  aorta  and  vena  cava  unite  the  retro-aortic 
group  to  the  glands  placed  in  front  of  these  vessels. 

The  retro-aortic  glands  receive  the  lymphatics  coming  from  three 
of  the  preceding  groups,  viz.  the  prae-aortic  and  the  right  and  left 
juxta-aortic  groups.  Their  efferent  vessels  pass  into  the  recepta- 
culum  chyli. 

To  sum  up,  the  afferent  vessels  of  the  retro-aortic  glands  are 
almost  entirely  made  up  of  the  efferents  of  the  prae  and  juxta- 
aortic  glands  ;  these  retro-aortic  glands  are  not  therefore  true  regional 
glands  (vide  p.  86),  but  simply  constitute  a  fresh  relay  interposed 
between  the  preceding  groups  and  the  receptaculum  chyli. 
Moreover,  we  must  recollect  that  certain  efferents  of  the  preceding 
groups  end  directly  in  the  receptaculum,  or  even  in  a  suprajacent 
segment  of  the  thoracic  duct,  by  passing  through  the  pillars  of  the 
diaphragm  (vide  Fig.  114). 

§  11.— THE  LYMPHATIC  VESSELS  OF  THE  PELVIS  AND 

ABDOMEN. 

We  will  now  study  the  lymphatics  of  the  abdominal  wall, 
the  lymphatics  of  the  male  and  female  external  and  internal 
genital  organs,  the  lymphatics  of  the  urinary  organs,  and 
finally  the  lymphatics  of  the  subdiaphragmatic  portion  of  the 
digestive  tube  and  its  annexa. 

I.  THE  LYMPHATICS  OF  THE  ABDOMINAL  WALL. 
We  may  divide  the  lymphatics  of  the  abdominal  wall  into  the 


LYMPHATICS  OP  THE  PELVIS  AND  ABDOMEN      149 

superficial  or  cutaneous  lymphatics,  and  deep,  aponeurotic  or  mus- 
cular lymphatics. 

(1)  THE    SUPERFICIAL  LYMPHATICS    may   themselves    be   divided 
into  anterior  and  posterior. 

(a)  The  anterior  as  they  descend,  converge  towards  the  inguinal 
region  and  terminate  in  the  supero-external  and    supero-internal 
groups  of  the  superficial  inguinal  glands.     The  vessels  which  arise 
near   the  costal  margin    have   however  an  entirely  different  ter- 
mination, inasmuch  as  they  are  tributaries  of  the  axillary  glands. 

(b)  The  posterior  arise  from  the  integuments  of  the  lumbar  region. 
Anastomosing  above  with  the  lymphatics  of  the  back,  and  below  with 
the  lymphatics  of  the  gluteal  region,  they  give  origin  to  three  or  four 
collecting  trunks,  which  run  downwards  and  forwards,  coursing  a 
little  above  and  parallel  to  the  iliac  crest ;  they  terminate  in  the 
supero-external  group  of  the  superficial  inguinal  glands. 

(2)  THE  DEEP  LYMPHATICS  arise  either  from  the  different  aponeur- 
oses,  or  from  the  fleshy  portions  of  the  different  muscles  of  the  ab- 
dominal wall.  They  group  themselves  into  four  principal  channels  ;  (a) 
A  channel  which  is  a  satellite  of  the  deep  epigastric  artery,  the  con- 
stituent vessels  of  which,  after  traversing  the  epigastric  glands,  ter- 
minate in  the  external  and  internal  retro-crural  glands,     (b).  A 
channel  which  accompanies  the  deep  circumflex  iliac  artery  and  ends 
in  the  external  retro-crural  gland,      (c)  A  lumbar  channel  comprising 
four   to   five   trunks,  which   are  satellites  of    the  lumbar   arteries 
and  tributaries  of  the  juxta-aortic  glands,    (d)  An  ascending  channel, 
which  is  a  satellite  of  the  abdominal  branch  of  the  internal  mammary 
artery,  the  constituent  vessels  of  which  terminate  in  the  internal 
mammary  chain. 

There  is  one  region  of  the  abdominal  wall  where  the  lymphatics 
from  a  practical  point  of  view,  have  a  particular  interest :  this  is  the 
umbilical  region.  We  will  therefore  devote  a  few  lines  to  the 
study  of  the  lymphatics  cf  the  umbilicus. 

LYMPHATICS  OF  THE  UMBILICUS. — We  may  divide  the  lymphatics 
of  the  umbilicus  into  three  groups  :  (1)  The  cutaneous  lymphatics  ; 
(2)  The  lymphatics  of  the  fibrous  nucleus  ;  (3)  The  lymphatics  of 
the  aponeurotic  edge  of  the  ring. 

(1)  The  cutaneous  lymphatics  arise  in  the  foetus  and  in  the  newborn 
infant  from  the  umbilical  scrotum,  and  in  the  adult  from  the  skin 
which  covers  the  fibrous  nucleus  of  the  umbilicus.  Their  network  of 
origin,  which  is  extremely  close,  is  continuous  with  that  of  the 
surrounding  skin.  From  this  network  four  or  five  trunks  on  either 

K* 


150 


SPECIAL    S1TDY    (JF    THE    LYMPHATICS 


side  run  downwards  and  outwards  towards  the  centre  of  the  inguinal 
region  ;  these  lymphatic  trunks  run  immediately  beneath  the  in- 
teguments in  a  more 
superficial  plane  than 
the  subcutaneous  ab- 
dominal lymphatics, 
whose  course  they  follow. 
They  terminate  in  the 
supero  -  internal  and 
supero-external  groups 
of  superficial  inguinal 
glands  (vide  p.  116).  It 
is  exceptional  to  see 
these  descending  trunks 
cross  one  another  in 
the  middle  line.  On  the 
other  hand,  vessels  of  the 
same  side  often  cross 
each  other,  and  one  of 
the  most  internal  trunks 
ma}'  be  seen  to  termin- 
ate in  one  of  the  more 
external  of  the  superior 
inguinal  glands  (vide 
Fig.  51). 

On  puncturing  at  the  actual  level  of  the  umbilicus,  we  never  really 
inject  any  vessel  terminating  in  the  axillary  glands.  To  inject  the 
tributary  trunks  of  these  glands,  the  puncture  must  be  made  at  some 
distance  above  the  umbilicus  (Cuneo  and  Marcille). 

(2)  The  lymphatics  of  the  fibrous  nucleus, which  are  much  more 
difficult  to  inject  than  the  preceding,  have  an  entirely  different  ter- 
mination.    On  each  side  of  the  nucleus,  three  to  four  trunks  may  be 
seen  to  arise  which  at  once  penetrate  the  sheath  of  the  recti,  and 
embrace  the  deep  epigastric  artery,  which  at   this   level   is  intra- 
muscular.    Lower   down,  they  are  situated  over  the  artery  itself, 
between  the  muscle  and  the  posterior  part  of  its  sheath :  they  then 
appear  under  the  fold  of  Douglas,  where  they  unite  with  the  lym- 
phatics which  arise  from  the  aponeuroses  which  form  the  posterior 
wall  of  the  sheath  of  the  recti  muscles. 

(3)  The  lymphatics  of  the  aponeurotic  edge  of  the  ring  are  divided 
into  anterior  and  posterior.    The  anterior  lymphatics  (vide  Fig.  49,a) 


FIG    49. — Lymphatics   of  the  umbilical  coverings 
(Cuneo  and  Alarcille). 

a.  Lymphatic  tributary  of  the  axillary  glands. — 
b.  Prae-aponeurotic  network,  c.  Tributary  trunk  of  the 
inguinal  glands. — d.  Supero-external  inguinal  gland. — 
e.  Supero-internal  inguinal  gland. — /.  Infero-external 
inguinal  gland. 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      151 

arise   from     an    extremely    loose    network,     attached    all    round 
the  umbilicus  on  the  anterior  surface  of  the  aponeurotic  sheath  of 


Fic.  50. — Lymphatics  of  the  umbilicus  (posterior  view),  (Cuneo  and  Marcille). 
a.  Retro-Rponeurotic  network. — 6.  Satellite  trunk  of  the  lumbar  artery. — o.  Gland  of  the 
epigastric  chain. — d,  c.    Retro-crural   internal    gland. — /.  Retro-crural   external   gland. — g 
Satellite  trunks  of  deep  epigastric  artery. — h.  Satellite  trunk  of  the  umbilical  vein. — i.  Supra- 
umbilical  glandular  nodules. — /.  The  infra-umbilical  gland. 

the  recti.  They  terminate  in  two  systems  of  collecting  trunks. 
Some  (a)  perforate  the  aponeurotic  lamina  of  the  umbilicus,  gain  the 
sheath  of  the  recti,  and  unite  with  the  lymphatics  of  the  fibrous 
nucleus.  Others  (6)  pass  externally,  perforate  the  internal  and 
external  oblique  muscles  and  blend  with  homologous  trunks 
coming  from  the  posterior  part  of  the  aponeurosis.  the  termina- 
tion of  which  we  will  shortly  indicate. 

The  posterior  lymphatics  (Fig.  50)  give  rise  to  a  peri-umbilical  net- 
work placed  on  the  posterior  surface  of  the  sheath  of  the  recti.  From 
this  network  run  two  systems  of  collecting  trunks.  Some  (a)  run 
externally,  perforate  the  trans versalis,  and  run  between  this  muscle 
and  the  internal  oblique.  Joining  with  homologous  lymphatics 
coming  from  the  anterior  part  of  the  aponeurosis  they  pass  either 
to  the  external  retro-crural  gland  (vide  p.  130),  following  the 
course  of  the  deep  circumflex  iliac  artery,  or  accompanying  a  lumbar 


152  SPECIAL    STUDY    OF    THE    LYMPHATICS 

artery,  pass  to  a  juxta-aortic  gland.  Others  (b)  run  downwards, 
unite  with  the  vessels  coming  from  the  fibrous  nucleus,  and  keeping 
more  or  less  in  contact  with  the  deep  epigastric  artery,  terminate  in 
the  two  external  iliac  glands  which  are  placed  immediately  behind 
the  crural  ring,  viz.  the  retro-crural  external,  and  the  retro-crural 
internal  gland  (/  and  e),  Fig.  5.0  (vide  p.  139). 

In  the  lower  third  of  the  course  of  these  lymphatic  trunks, 
we  meet  with  three  to  six  glands,  which  are  small  but  almost  always 
present.  These  are  the  glands  of  the  epigastric  chain  (the  inferior 
epigastric  glands  of  Gerota)  which  we  have  already  had  occasion  to 
point  out  (vide  pp.  134  and  135). 

In  some  cases, we  may  come  across  a  little  gland  in  the  subperitoneal 
retro-umbilical  cellular  tissue.  Gerota,  who  was  the  first  to  point  out 
its  existence,  met  with  it  twice  in  ten  subjects.  This  gland  is  usually 
2  to  4  centimetres  from  the  umbilicus  and  is  almost  always  placed  a 
little  laterally.  It  presents  a  certain  interest  from  the  pathological 
point  of  view,  for  it  may  be  the  point  from  which  certain  suppurative 
processes  in  this  region  may  start,  and  which  clinically  corresponds 
to  what  has  been  described  as  the  phlegmon  of  Heurtaux  (Cuneo 
and  Marcille). 

In  the  new-born  infant  Cuneo  and  Marcille  have  met  with  two  small  glands 
which  are  placed  above  the  umbilicus  in  the  subperitoneal  cellular  tissue  (vide 
Fig.  50).  These  glands  receive  the  lymphatics  which  come  from  the  supra- 
umbilical  portion  of  the  network  which  is  attached  to  the  posterior  portion  of 
the  sheath  of  the  recti. 

Finally,  we  may  add  that  the  lymphatics  of  the  umbilicus  communicate 
with  those  of  the  bladder  by  means  of  networks  which  surround  the 
urachus,  and  with  those  of  the  liver  by  very  fine  vessels  which  run  the  whole 
length  of  the  umbilical  artery.  These  communications  enable  us  to  under- 
stand the  pathogeny  of  certain  cases  of  secondary  cancers  of  the  umbilicus. 

BIBLIOGRAPHY.— SAPPEY,  loc.  cit.,  p.  50.— GEROTA.  Ueber  die  Lymph- 
gefasse  unci  die  Lymphdriisen  der  Harnblase.  Anat.  Anz.,  1896,'  XII, 
p.  89. — CUXKO  et  MARCILLE.  Note  sur  les  lymphatiques  de  1'ombilic.  Soc. 
anat.,  nov.  1901. 

II.  LYMPHATICS  OF  THE  EXTERNAL  GENITAL  ORGANS. 
We  will  study  (a)  the  lymphatics  of  the  external  genital  organs 
in  the  male  and  (b)  in  the  female.       As  we  shall  see,  these  vessels 
have  an  arrangement  which  is  identical  in  the  two  sexes. 

(a)  In    the    Male. 

LYMPHATICS  OF  THE  SCROTUM.— The  lymphatics  of  the  scrotum 
take  origin  from  an  extremely  rich  network ;  so  that  the  injection  of 
these  vessels  is  extremely  easy,  at  least  in  the  infant.  In  the  adult, 
the  fragility  of  the  meshes  of  the  network  renders  their  injection 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      153 

a  more  delicate  operation,  especially  when  mercury  is  used.  This 
network  covers  the  entire  surface  of  the  scrotum,  but  is  especially 
lense  about  the  raphe,  and  it  is  there  that  it  can  be  most  easily 
injected.  It  is  near  the  raphe,  too,  that  the  large  collecting  trunks 
appear  which,  later  on  in  their  course,  collect  the  small  branches 
coming  from  the  lateral  parts  of  the  scrotal  network.  These  trunks 
number  from  ten  to  fifteen  on  each  side.  They  may  be  dis- 
tinguished as  superior  and  inferior. 


10 


FIG.  51. — Glands  of  the  inguinal  region  ;  afferent  and  efferent  vessels.  (From  Sappey's 
Atlas.) 

1,  1.  The  two  lowest  glands  of  the  inguinal  region  are  remarkable  for  their  size. — 2. 
Infero-external  gland. — 3,  3.  Internal  inguinal  glands,  in  which  terminate  the  vessels  of  the 
scrotum,  perineum,  anal  region,  and  the  supero-internal  portion  of  the  integuments  of  the 
thigh. — 4.  Superior  and  internal  inguinal  gland  ;  it  receives  vessels  coming  from  the  urethral 
canal,  from  the  surface  of  the  glans,  and  from  the  integuments  of  the  penis. — 5,  5.  Supero- 
internal  and  external  inguinal  glands  ;  in  these  glands,  which  are  three  or  four  in  number, 
terminate  the  vessels  coming  from  the  sub-umbilical  portion  of  the  abdomen. — 6,  6.  Lym- 
phatic vessels  from  the  antero-internal  portion  of  the  thigh. — 7,  7.  Vessels  from  the  external 
portion  of  the  thigh. — 8,  8.  Vessels  from  the  gluteal  region. — 9,  9.  Vessels  from  the  lumbar 
region. — 10,  10,  10.  Vessels  from  the  sub-umbilical  portion  of  the  anterior  wall  of  the 
abdomen. — 11,  11.  Lymphatic  vessels  of  the  scrotum. — 12.  Lymphatic  vessels  of  the  pre- 
puce.— 13,  13.  Lymphatic  vessels  of  the  integuments  of  the  penis. — 14.  Lymphatic  trunk 
which  surrounds  the  corona  of  the  glans. — 15.  Median  trunk,  which  is  continuous  with  the 
preceding. — 10.  Umbilicus. 


154  SPECIAL    STUDY    OF    THE    LYMPHATICS 

(a)  The  superior  trunks  (median  trunks  of  Sappey),  arise  from 
that  portion  of  the  scrotal  raphe  which  is  immediately  continuous 
with  the  raphe  of  the  penis.  They  run  at  first  vertically  upwards, 
then  having  reached  the  root  of  the  penis,  curve  sharply  outwards. 
They  then  run  parallel  to  the  collecting  trunks  of  the  penis,  cross  the 
spermatic  cord  and  terminate  in  the  supero-internal  group  of  super- 
ficial inguinal  glands.  (On  the  nomenclature  of  these  glands,  vide  pp. 
114  and  115). 

(I)  The  inferior  trunks  (lateral  trunks  of  Sappey)  arise  from  the 
raphe,  below  and  behind  the  preceding.  They  run  upwards  and 
outwards  towards  the  lateral  parts  of  the  scrotum  ;  they  then  follow 
the  cruro-scrotal  groove,  which  they  quickly  leave,  and  then 
pass  directly  outwards  and  terminate  in  the  infero-external  and  in- 
fero-internal  glandular  groups. 

The  collecting  trunks  of  the  scrotal  network  frequently  anasto- 
mose with  those  from  the  penis,  and  perineum,  and  with  the 
trunks  coming  from  the  supero-internal  part  of  the, skin  of  the 
thigh. 

LYMPHATICS  OF  THE  PENIS. — The  lymphatics  of  the  penis 
comprise  :  (1)  the  lymphatics  of  the  cutaneous  coverings  of  the 
penis  ;  (2)  the  lymphatics  of  the  glans  ;  (3)  the  lymphatics  of  the 
penile  portion  of  the  urethra  ;  (4)  the  lymphatics  of  the  erectile 
structures.  Our  knowledge  of  the  latter  is  still  imperfect : 
moreover  their  collecting  trunks  are  in  all  probability  blended  with 
those  of  the  penile  urethra,  which  we  will  study  later  on  with  the 
lymphatics  of  the  other  portions  of  the  urethra  (vide  p.  175). 
We  shall  now  only  have  to  consider  the  cutaneous  lymphatics  and 
the  lymphatics  of  the  glans. 

(1)  THE  CUTANEOUS  Li'MPHATics.— The  cutaneous  lymphatics  may 
be  divided  into  two  groups  ;  the  lymphatics  of  the  sheath  of  the 
penis  and  the  lymphatics  of  the  prepuce. 

(a)  The  lymphatics  of  the  sheath  of  the  penis  are  fairly  numerous, 
but  difficult  to  inject.  They  form  a  network  with  fairly  regular 
meshes  which  is  continuous  in  front  with  the  network  of  the  prepuce. 
At  the  raphe,  the  meshes  become  finer  and  closer. 

In  this  situation  also  the  collecting  trunks  appear.  These  are 
four  or  five  in  number  and  the  more  anterior  their  origin  the  longer 
they  are.  They  turn  round  the  lateral  surfaces  of  the  penis, 
and  then  run  on  its  dorsal  surface;  they  then  pass  directly 
backwards  to  the  root  of  the  organ,  where  they  make  a  sharp  bend, 
and  turn  outwards  towards  the  inguinal  glands. 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      155 

(b)  The  lymphatics  of  the  prepuce  arise  from  a  very  fine  network 
which  follows  in  its  plicature  the  skin  of  the  praeputial  fold.  The 
lymphatics  of  the  superficial  portion  are  more  developed  than 
those  of  its  deep  or  reflected  portion.  In  the  balanitic  portion  of 
the  prepuce,  the  network  is  continuous  with  the  lymphatic  network 
of  the  glans. 

The  small  trunks  of  this  network  end  either  in  a  single  median 
collecting  trunk,  or  in  two  juxta-median,  or  in  multiple  collect- 
ing trunks.  Contrary  to  Sappey's  views,  Brulms  regards  this  latter 
arrangement  as  the  rule.  In  any  case  whatever  their  number,  these 
vessels  run  in  the  middle  of  the  dorsum  of  the  penis  by  the  side  of 
the  superficial  dorsal  vein,  and  anastomose  with  each  other  by 
branches  which  are  more  or  less  developed  in  different  subjects. 
These  vessels  are  however  especially  remarkable  for  their  sinuosities, 
on  which  point  Gerard  Marchant  has  laid  stress  :  they  are  caused 
by  alterations  in  size  of  the  penis.  When  several  trunks  are 
present,  they  divide  into  two  groups  at  .the  root  of  the  organ  ; 
when  only  one  trunk  exists,  it  usually  divides  into  two  secondary 
branches,  which  are  frequently  unequal  in  size.  This  trunk  may 
even  be  seen  to  remain  undivided  and  end  in  the  inguinal  glands 
of  one  side. 

Whether  their  point  of  exit  be  through  the  sheath  of  the  penis  or 
the  prepuce,  the  cutaneous  lymphatics  pass  towards  the  inguinal 
glands,  running  immediately  underneath  the  integument.  For  the 
greater  part,  they  terminate  in  the  supero-internal  group,  but  they 
may  also  end  in  the  other  glandular  groups  of  this  region  (vide  p. 
119  and  Fig.  51). 

In  the  case  of  a  neoplasm  of  the  integuments  of  the  penis, 
we  must  regard  all  the  superficial  inguinal  glands  as  liable  to 
become  infected.  Further,  by  reason  of  the  inter-crossing  or  the 
bifurcation  of  the  collecting  trunks,  there  is  a  strong  probability 
that  a  lesion  which  is  quite  clearly  unilateral  will  affect  the 
glands  of  the  opposite  side. 

(2)  LYMPHATICS  OF  THE  CLANS. — The  lymphatics  of  the  glans  arise 
from  a  network  with  very  fine  meshes,  which  has  been  perfectly 
described  by  Sappey.  This  network  is  partly  continuous  with  the 
network  of  the  prepuce,  and  that  of  the  balanitic  portion  of  the 
urethra.  From  this  network  run  a  series  of  small  collecting 
trunks.  "The  direction  of  the  latter  is  remarkable:  all  run 
from  before  backwards  towards  the  fraenum  of  the  penis, 
which  invariably  represents  their  centre  of  convergence.  On  the 


156  SPECIAL    STUDY    OF    THE    LYMPHATICS 

right  and  left  of  the  fraenum  they  receive   two  or  three   trunks 
coming  from  the  mucuous  membrane  of   the  urethra,    they   then 


FIG.  52.— Lymphatics  of  the  glans  in  the  new-born  infant  (Cuneo  and  Marcille). 
a.  Lateral  aortic  gland. — b.  Gland  of  the  promontory. — c.  External  iliac  gland  (internal 
chain). — d.  Retro-crural  internal  gland. — e.  Glandular  nodule  placed  at  the  entrance  of  the 
inguinal  canal. — /.  Praesymphysian  glandular  nodule. — g.  Collecting  trunks  of  the  network 
of  the  mucous  membrane  of  the  glans. — h.  Network  of  the  mucous  membrane  cover- 
ing the  glans. — i.  Gland  of  the  promontory. — /.  External  iliac  gland  (middle  chain). — k. 
Retro-crural  external  gland. — /.  Crural  collecting  trunks  of  the  glans. 

bend  backwards,  and  arrange  themselves  behind  the  corona  of  the 
glans  round  which  they  turn  ;  they  then  mount  upwards  as  far  as  its 
median  part,  where  those  of  one  side  unite  with  those  of  the  opposite 
side  "  (Sappey).  According  to  Sappey,  they  blend  into  a  single 
trunk  which  ends  in  the  superficial  inguinal  glands.  The  researches 
of  Kiittner,  Bruhns,  Cuneo  and  Marcille  have  not  confirmed  the 
description  given  by  Sappey.  According  to  these  authors,  the 
lymphatics  of  the  glans  end  in  multiple  collecting  trunks,  which 
vary  from  two  to  four  in  number. 

These  vessels  run  parallel  to  the  deep  dorsal  vein  of  the  penis  ; 
and  so  are  sub-aponeurotic.  They  thus  arrive  at  the  root  of  the 
penis,  in  front  of  the  symphysis,  where  they  effect  some  anasto- 
moses and  thus  form  a  sort  of  praesymphysian  plexus  with  very 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      157 

large  meshes.  At  this  spot  may  be  found  some  small  glands  which 
belong  to  the  group  of  interrupting  glandular  nodules  (vide  p.  86) 
and  which  we  will  term  praesymphysial  glandular  nodules  (vide 
Fig.  52). 

From  this  praesymphysial  plexus  run  several  collecting  trunks 
which  follow  a  different  course  ;  some  run  towards  the  crural  canal 
(the  crural  route),  others  pass  into  the  inguinal  canal  (the  inguinal 
route). 

(a)  The   crural    trunks,    three    to  four   in    number,  run    trans- 
versely   outwards,    passing    beneath    the    femoral  aponeurosis,    in 
front  of  the  pectineus.  At  first  grouped  in  a  single  bundle,  they  soon 
diverge  in  the  vertical  direction.     The  lowest  of  them  terminates  in  a 
deep  inguinal  gland,  which  is  lodged  in  the  crural  canal,  internal  to 
the  femoral  vein.     The  suprajacent  trunk  terminates  in  the  gland 
of  Cloquet ;  the  third  crosses  the  crural  canal,  enters  the  pelvis,  and 
ends  in  the  internal  retro-crural  gland   (vide  TOPOGRAPHY  OF  THE 

PELVIC    GLANDS,  p.     129). 

In  short,  they  all  end  in  a  series  of  glands  vertically  placed 
one  above  the  other,  and  ranged  along  the  femoral  vein,  and  the 
external  iliac  vein.  This  route  is  therefore  partly  femoral,  and 
partly  pelvic. 

(b)  The  inguinal  route  usually  only  comprises  a  single  trunk,  which 
passes  into  the  inguinal  canal,  and  which  runs  underneath  the  sper- 
matic cord,  which  must  be  raised  to  see  it.    It  may   present  in  its 
course    a    small    interrupting    glandular  nodule,   which  is  usually 
placed  at  the  entrance  of  the  inguinal  canal.     This  trunk  terminates 
in  the  external  retro-crural  gland. 

Bruhns  maintains  that  some  of  the  collecting  trunks  which  come  from  the 
glans  end  in  the  superficial  inguinal  glands.  We  only  admit  this  termination, 
as  an  anomaly,  and  are  of  opinion  that,  when  by  puncturing,  the  gians,  the 
superficial  glands  become  injected,  it  is  because  the  injection  has  penetrated 
into  the  plexus  of  the  prepuce. 

Kiittner  has  seen  a  trunk  embrace  the  large  vessels,  ascend  beneath  them 
to  a  gland  placed  on  the  spot  where  the  ureter  enters  the  pelvic  cavity. 
This  is  a  very  rare  arrangement.  Kiittner  also  described  a  trunk  which, 
coming  from  the  praesymphysian  network,  passed  between  the  recti,  and 
terminated  in  a  hypogastric  gland  (?)  and  in  a  gland  placed  a  little  internal 
to  the  epigastric  vessels.  We  think  this  too  is  an  anomaly. 

We  should  a  priori  expect  to  find  the  collecting  trunks  closely  accompanying 
the  dorsal  artery  of  the  penis,  and  then  following  the  internal  pudic.  These 
vessels  do  exist,  but  do  not  come  from  the  glaris.  According  toCuneo  and 
Marcille,  they  come  exclusively  from  the  urethra. 

BIBLIOGRAPHY.— -MASCAGNI,  loc.  cit.,  p.  38  et  tab.  XI.— SAFPEY,  loc.  cit., 
p.  51  et  pi.  VII. KCTTNEJK.  Zur  Verbreitung  und  Prognose  des  Peniscar- 


158  SPECIAL    STUDY    OF    THE    LYMPHATICS 

cinoms,  Arch.  /.  klin.  Chir.,  1899,  LIX,  1,  p.  180.— BRUHXS.  Ueber  die 
Lymphgefasse  der  ausseren  mannlichen  Geiiitalieii  und  die  Zuflusse  der 
Leistendriisen.  Arch.  /.  Anat.  u.  Phys.,  An.  Abth.,  1900,  p.  281.—  CUXEO  et 
MARCILLE.  Note  sur  les  lymphatiques  du  gland.  Bull.  Soc.  anat.. 
decembre  1901. 

(b)   In  the   Female. 

LYMPHATICS  OF  THE  VULVA.— The  lymphatics  of  the  vulva  arise 
from  a  network  the  extremely  close  meshes  of  which  are  superposed 
in  several  planes.  "  This  network  covers  the  fourchette,  the 
meatus  urinarius,  the  vestibule,  the  clitoris,  the  labia  minora, 
and  the  internal  surface  of  the  labia  majora  ;  it  is  so  loose  and 


FIG.  53.— Lymphatics  of  the  clitoris  (Cuneo  and  Marcille). 

a.  Right  juxta-aortic  gland. — 6.  Gland  of  Cloquet. — r.  Deep  inguinal  gland.— -d.  Common 
iliac  gland  (external  gland). — e.  External  iliac  gland  (external  chain). — g.  Lymphatic 
vessel  of  the  clitoris  taking  an  inguinal  course. 

close  throughout  that  when  it  has  been  well  injected,  it  presents  at 
first  sight  merely  an  ashy  grey  appearance.  To  distinguish  the  in- 
numerable silvery  filaments  of  which  it  is  composed,  we  must  use  a 
magnifying  glass.  On  the  external  surface  of  the  labia  majora,  the 
network,  composed  of  smaller  and  larger  branches,  becomes  suffi- 
ciently distinct  to  be  recognized  by  the  naked  eye."  (Sappey.) 

From  the  periphery  of  this  network  of  origin  run  the  collecting 
trunks.  The  direction  of  these  trunks  varies  according  to  their 
points  of  origin.  Those  which  come  from  the  anterior  third  of 
the  vulva,  run  directly  upwards,  and  forwards  towards  the  rnons 
Veneris ;  there,  they  turn  sharply  and  run  transversely  towards 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      159 

the  superficial  inguinal  glands.  The  trunks  which  come  from  the 
posterior  two-thirds  are  directed  upwards  and  outwards,  and  directly 
reach  their  terminal  glands. 

The  majority  of  the  lymphatics  of  the  vulva  terminate  in  the 
glands  of  the  supero-internal  group.  Some  of  them  may  end  in  the 
infero-internal  group.  It  is  even  possible,  though  much  more  rare, 
to  see  some  of  these  vessels  reach  a  gland  belonging  to  one  of  the 
two  external  groups.  As  has  been  seen,  the  vulvar  lymphatics  are 
far  from  being  confined  to  a  perfectly  definite  glandular  group. 

When  injecting  one  half  of  the  vulva,  the  mass  may  frequent- 
ly be  seen  to  reach  the  glands  of  the  opposite  side.  The  injection 
of  these  glands  may  take  place  by  a  double  process.  Sometimes 
it  is  effected  on  account  of  the  continuity  of  the  network  of  origin 
of  the  two  sides  of  the  vulva  in  the  middle  line  ;  at  others 
it  is  due  to  the  fact  that  some  of  the  collecting  trunks  cross 
the  middle  line,  and  end  in  the  inguinal  region  of  the  opposite 
side.  In  all  cases,  when  dealing  with  an  epithelioma  of  the  vulva, 
the  inguinal  glands  of  both  sides  should  be  regarded  as  liable  to 
infection. 

LYMPHATICS  OF  THE  CLITORIS. — The  lymphatics  of  the  clitoris 
deserve  special  mention.  In  fact,  though  the  lymphatics  of  the 
prepuce  of  the  clitoris  pass  into  the  superficial  inguinal  glands, 
like  the  other  lymphatics  of  the  vulva,  this  is  not.  the  case  with 
the  lymphatics  of  the  glans  of  the  clitoris.  These  latter,  which 
were  passed  over  in  silence  by  the  older  writers,  have  recently 
been  studied  by  Marcille  and  one  of  the  present  writers.  As 
their  general  arrangement  is  identical  with  that  of  the  lym- 
phatics of  the  glans  in  the  male,  we  will  content  ourselves  by 
indicating  it  briefly. 

As  in  the  male,  the  network  of  origin  gives  rise  to  several 
collecting  trunks  which  run  on  the  dorsal  surface  of  the  clitoris, 
and  reach  the  front  of  the  symphysis  ;  they  anastomose  at  this  spot, 
and  form  a  praesymphysial  network  in  which  some  small  glands 
may  be  seen  (vide  Fig. 53).  From  this  plexus  run  two  sets  of  collect- 
ing' trunks— (a).  One  of  these  vessels  runs  in  the  inguinal  canal,  and 
ends  in  the  external  retro-crural  gland.  This  vessel  is  usually 
placed  beneath  the  round  ligament,  and  may  show  in  its  course 
a  small  interrupting  glandular  nodule.  (6.)  Other  trunks  run  towards 
the  crural  canal  and  end  in  a  deep  inguinal  gland,  in  the  gland 
of  Cloquet,  and  in  the  internal  retro-crural  gland. 

BIBLTOGRAPHY.-SAPPEY,  loc.  cit.,  p.  54  et  pi.  VIII,  Fig.  1,  2,  S.-BBUHXS. 


160 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


Ueber  die  Lymphgefasse  cler  weibl.  Genitalien,  etc.  Arch.  /.  Anat.  u.  Pliys., 
Ariat.  Abth.,  1898,  p.  59.— CUNEO  et  MARCILLE.  Note  sur  les  lymphatiques 
du  clitoris.  Bull.  Soc.  anat.,  novembre  1901. 

III.     LYMPHATICS  OF  THE  INTERNAL  GENITAL  ORGANS. 
These  we  will  study  first  in  the  male  and  then  in  the  female. 

(a.)   In  the  Male. 

LYMPHATICS  OF  THE  TESTICLE.— The  lymphatics  of  the  testicle, 
whose  mode  of  origin   we  will  study  further  on  (vide  Treatise  of 


11  - 


FIG.  54.— Terminal  glands  of  the  lymphatics  of  the  testicle  in  a  new-born  infant. 
1.    Left   supra-renal   capsule. — ±    Left   spermatic   vein. — 3.    Left   juxta-aortio  gland. — 4. 
Inferior  mesenteric  artery. — 5.  Hype-gastric  artery. — 6.  Rectum. — 7.  Right  phrenic  artery. 
— 8.  Superior  mesenteric  artery. — 9.   Right  juxta-aortic  gland. — 10.  Ureter.— 1 1.    Posterior, 
gland  of  the  middle  chain  of  the  external  iliac  group. 

Human  Anatomy.  Poirer  and  Charpy,  vol.  v.  p.  269),  unite  with  the 
lymphatics  of  the  epididymis,  and  the  visceral  layer  of  the 
tunica  vaginalis,  and  run  towards  the  lumbar  region  along  the 
spermatic  cord. 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      161 

They  are  usually  more  superficial  than  the  blood-vessels  with 
which  they  are  in  immediate  contact.  In  our  preparations  they 
varied  from  four  to  eight  in  number.  Owing  to  the  division  of 
some  of  these  vessels,  it  has  appeared  to  me  that  this  number, 
far  from  becoming  reduced  during  their  course,  on  the  contrary 
increases. 

Having  arrived  in  the  lumbar  region  these  trunks  leave  the  sper- 
matic vessels  and  run  towards  their  terminal  glands,  either  describ- 
ing a  fairly  regular  curve,  or  sharply  bending  at  a  right  or  even 
on  acute  angle. 

The  trunks  coming  from  the  right  testicle  terminate  in  the  right 
juxta-aortic  glands.  The  lowest  of  these  glands  situated  immedi- 
ately above  the  bifurcation  of  the  inferior  vena  cava,  alwa}^s 
receives  one  or  two  afferent  trunks.  In  a  third  of  the  cases 
one  or  two  of  these  lymphatics  empty  themselves  into  one  of  the 
prae-aortic  glands. 

The  trunks  of  the  left  side  end  in  the  three  or  four  glands  of 
the  left  juxta-aortic  group,  which  are  arranged  in  rows  below  the 
renal  vessels,  but  here  again,  we  may  sometimes  see  that  some 
lymphatics  are  not  arrested  in  the  glands  of  this  group,  but 
directly  reach  the  prae-aortic  glands. 

Most  remarks  that  the  glands  which  receive  the  lymphatics  of 
the  left  testicle,  are  placed  at  a  somewhat  higher  level  than  those 
which  receive  the  trunks  coming  from  the  right  testicle.  In  a  third 
of  the  cases,  however,  these  two  glandular  groups  are  clearly 
placed  at  the  same  level. 

Zeissl  and  Horowitz  have  described  as  constant,  a  vessel  which  they  ob- 
served on  puncturing  the  internal  surface  of  the  testicle:  this  vessel,  at  first 
a  satellite  of  the  vas  deferens,  leaves  this  duct  and  terminates  in  one  of  the 
elands  of  the  external  iliac  chain.  This  vessel  has  not  been  noticed  by  the 
older  writers.  Most  was  unable  to  inject  it  in  man,  and  was  only  successful 
in  showing  it  in  the  rat  and  dog.  One  of  the  present  writers  has  injected  it  in 
several  subjects,  and  has  seen  it  end  in  a  gland  placed  on  the  external  iliac 
vein  immediately  in  front  of  the  spot  where  this  vein  is  crossed  by  the  ureter. 
In  all  probability  then,  the  arrangement  is  a  constant  one,  but  we  must 
agree  with  Most  that  this  vessel  is  somewhat  difficult  to  inject. 

In  a  full-term  foetus,  one  of  the  authors  noted  the  existence  of  three  little 
glands  placed  over  the  lymphatics  of  the  testicle,  in  their  course  through  the 
iliac  fossa.  This  arrangement  must  be  somewhat  rare,  seeing  that  it 
has  not  been,  mentioned  at  all  in  anatomical  literature,  and  that  out  of 
eighteen  subjects  examined  by  us  we  have  only  come  across  it  once. 

BIBLIOGRAPHY. — Pour  les  indications  concernant  1'origine  des  vaisseaux, 
voy.  t.  V.  p.  270  et  REGAUD,  Th.  dp,  Lyon,  1897. — GERSTER.  Ueber  die 
Lyraphagefasse  des  Hodens.  Zeitsch.  f.  Anat.  u.  Entwickelung.,  t.  II,  1876.— 
ZEISSL  i°  HOROWITZ,  Wiener  klinische  Wochenschr.,  1890,  p.  388  et  Wiener 


162  SPECIAL    STUDY    OF    THE    LYMPHATICS 

medicinische  Presse,  XXXVIII,  p.  761. — MOST.  Ueber  maligne  Hodentumoren 
u.  ihre  Metastasen.  Virchow's  Arch.,  1898,  CLIV,  p.  138. — MOST.  Ueber 
die  Lymphgefasse  n.  Lymphdriisen  des  Hodens.  Arch.  /.  Anat.  n.  Phys., 
Anat.  Abth.,  1899,  p.  113,  av.  1  fig. — CUNEO.  Note  sur  les  lymphatiquea  du 
testicule,  Bull.  Soc.  anat.,  fevrier  1901. 

LYMPHATICS  OF  THE  VAS  DEFERENS. — Though  it  may  be  taken 
for  granted  that  the  lymphatics  of  the  vas  deferens  arise  from  two 
networks,  one  of  which  is  in  connection  with  the  mucous,  and  the 
other  with  the  muscular  coat ;  up  to  the  present  time  no  one 
has  succeeded  in  injecting  the  mucous  network.  Moreover,  the 
lymphatics  of  the  vas  deferens  are  remarkably  thin,  especially  in 
its  middle  part  (Sappey). — The  collecting  trunks  pass  to  the 
external  retro-crural  gland  and  to  the  posterior  gland  of  the 
middle  chain  of  the  external  iliac  glands. 

LYMPHATICS  OF  THE  VESICULAE  SEMINALES.— The  lymphatics 
of  the  vesiculae  seminales  are  much  easier  to  inject,  and  much  more 
is  known  about  them.  They  arise  from  two  networks,  one 
mucous,  and  the  other  muscular. 

The  trunks  coming  from  this  network  anastomose  one  with 
another  on  the  surface  of  the  vesiculae,  and  thus  constitute  a  third 
network,  from  which  the  collecting  trunks  originate.  Though  our 
researches  have  not  been  sufficiently  numerous  to  enable  us  to 
determine  with  certainty  the  course  of  these  collecting  trunks, 
we  would  willingly  regard  as  normal  the  existence  of  two  vessels, 
one  of  which  goes  to  the  posterior  gland  of  the  middle  chain  of 
the  external  iliac  glands,  while  the  other  terminates  in  a  gland  of 
the  hypogastric  group. 

The  lymphatics  of  the  vesiculae  seminales  anastomose  to  a  large 
extent  with  those  of  the  bladder  and  especially  with  those  of  the 
prostate. 

(b)  In  the  Female. 

LYMPHATICS  OF  THE  OVARY.— The  lymphatics  of  the  ovary, 
whose  mode  of  origin  we  shall  study  later  on  (vide  vol.  v.  p.  370 '), 
are  remarkable  for  their  numbers.  In  well-injected  preparations, 
they  form,  even  at  the  hilum,  a  plexus  of  the  greatest  richness, 
the  close-set  meshes  of  which  entirely  prevent  the  subjacent  venous 
plexus  from  being  seen.  Little  by  little  the  plexus  diminishes  in  size  : 
it  finally  resolves  itself  into  four,  five,  or  six  lymphatic  trunks,  which 
immediately  take  an  upward  course  ;  these  trunks,  which  accompany 
the  ovarian  vessels,  run  with  them  under  the  peritoneum,  pass  in 
front  of  the  common  iliac  vessels,  then  cross  the  ureter,  and 
terminate  in  the  lumbo-aortic  glands.  Our  injections  with  mercury 

1  Treatise  of  Human  Anatomy,  Poirierand  Charpy. 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      163 


and  with  Gerota's  solution  have  shown  us  that  the  arrangement  of 
their  terminal  glands  is  precisely  the  same  as  that  of  the  glands 
which    receive   the   lymphatics    of    the    testicle,    that    is    to   say, 
they  terminate  in  the  lateral-aortic  glands  of  the  corresponding  side. 
In  this  ascending  course,  the  lymphatics  of  the  ovary  unite  with 
the     lymphatics     com- 
ing from  the  fundus  of 
the    uterus    and    from 
the  Fallopian  tube  ;  but 
at  first  they  are  simply 
placed    next    to    these 
vessels,  and  it  is   only 
when    they    reach    the 
level  of  the  5th  lumbar 
vertebra,  that  they 
commence  to  exchange 
anastomoses  with  them 
(Poirier).    In  the  course 
of     the    ovarian     lym- 
phatics, small  interrupt- 
ing   glandular    nodules 
may   be    found  (Stahr, 
Marcille). 

From  the  ovary  also 
a  vessel  may  be  seen, 
which  runs  downwards 
and  slightly  outwards, 
into  the  upper  part 
of  the  broad  ligament 
and  ends  in  one  of  the  glands  of  the  middle  chain  of  the  internal  iliac 
group  (Marcille).  In  this  connection  we  may  recollect  that  Zeissl 
and  Horowitz,  and  subsequently  one  of  the  authors,  have  seen  one 
of  the  lymphatics  of  the  testicle  end  in  this  same  gland. 

LYMPHATICS  OF  THE  FALLOPIAN  TUBE.— Arising  from  the  three 
coats  of  this  organ  (vide  vol.  v.  p.  393 *)  the  lymphatics  of  the 
tube  unite  with  those  of  the  uterus  and  ovary,  and  share  with 
them  their  mode  of  termination  in  the  two  lateral  chains  of  the 
abdomino-aortic  group. 

LYMPHATICS  OF  THE  UTERUS.— As  we  shall  see  later  on  (vol.  v. 
p.  481 1),  the  lymphatics  of  the  uterus  arise  from  three  capillary 

1  Treatise  of  Human  Anatomy,  Poirier  and  Charpy. 


-Scheme  of  the  lymphatics   of  the  uterus 

(Cuneo  and  Marcille). 
a.  Lumbar  pedicle  of  the  body. — 6.  External  iliac 
gland. — c.  External  iliac  pedicle  of  the  body. — d.  Pedicle 
of  the  round  ligament. — e.  Hypogasuic  pedicle  of  the 
neck. — /.  Pedicle  of  the  promontory. — g.  Gland  of  the 
promontory. — h.  Lateral  sacral  gland. — i.  Hypogastric 
gland. — j.  External  iliac  pedicle  of  the  neck. 


164 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


networks,  viz.  :  a  mucous,  a  muscular,  and  a  peritoneal  network. 
The  trunks  originating  from  these  three  networks  of  origin  all 
assemble  on  the  surface  of  the  uterine  muscle  in  the  sub- 
peritoneal  cellular  tissue,  where  they  form  by  their  anastomosis, 
a  fourth  and  final  network  from  which  the  collecting  trunks  start. 
Though  the  networks  of  origin  of  the  cervix  and  of  the  body  are 


Fig.  50. — Lymphatics  of  the  uterus  (Cuneo  and  Marcille). 

o.  Lumbar  pedicle  of  the  body. — b  and  c.  External  iliac  pedicle  of  the  neck. — d.  External 
iliac  pedicle  of  the  body. — e.  Juxta-cervical  lymphatic  knot. — /.  Gland  of  the  promontory. 
— g.  Pedicle  of  the  promontory  of  the  neck. — /<.  Intrapelvicgluteal  gland. — {.  Lateral  sacral 
glands. — /.  Hypogastric  pedicle  of  the  neck. — k.  Lateral  sacral  pedicle  of  the  neck. 

continuous  with  each  other  without  any  line  of  demarcation,  we  will 
study  the  collecting  trunks  of  these  two  portions  of  the  uterus 
quite  separately. 

(1)  COLLECTING  TRUNKS  OF  THE  NECK  OF  THE  UTERUS. — The  cervical 
collecting  trunks  converge  towards  the  lateral  portions  of  the  body 
of  the  uterus.  They  vary  in  number  from  five  to  eight,  and  not  from 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN         165 

two  to  four  as  the  older  writers  stated.  After  leaving  the  cervix,  these 
trunks,  which  are  twisted  and  dilated,  form  a  large  lymphatic  knot, 
which  was  well  described  by  one  of  the  present  writers  in  1890,  and 
which  we  must  avoid  mistaking  for  a  gland.  This  juxta-cervical 
knot,  which  is  always  well  developed  in  the  pregnant  female,  is, 
on  the  contrary,  often  absent  in  the  new-born. 

The  cervical  collecting   trunks   may  be  subdivided  into  three 
;:  pedicles." 

(a)  A     primary    pedicle    (external   iliac   pedicle,    transverse   or 
prae-ureteric  pedicle)  comprises  two  to  three  trunks  which  run  at  first 
directly  outwards,  passing  in  front  of  and  above  the  ureter.  Excep- 
tionally, one  of  them  may  pass  behind  and  beneath  this  duct.     At 
first  satellites  of  the  uterine  artery,  they  soon  leave  this  vessel.    They 
then  run  up  the  lateral  Avail  of  the  pelvic  cavity,  passing  internal  to 
the  hypogastric  artery,  which  they  are  obliged  to  cross  in    the 
foetus.    They  terminate  in  the  middle  and  superior  glands  of  the 
middle  chain  of  the  external  iliac  group   (vide  Fig.  56).     At  the 
level  where    these  vessels  cross    the  ureter,  we  may  find    as    an 
abnormality,  an  interrupting  glandular  nodule,  which,  when  of  fair 
size,  constitutes  a  true  juxta-cervical  gland. 

Juxta-cervical  gland. — The  existence  of  this  gland  has  been  much  dis- 
cussed. Cruikshank,  Mascagni,  and  nearer  our  own  time,  Henle,  Luschka, 
and  Cruveilhier  do  not  mention  it.  M.  Lucas  Championniere  was  the  first 
to  notice  the  presence  of  a  gland  in  the  neighbourhood  of  the  cervix  of  the 
uterus.  "  I  have  often  seen,  and  have  had  a  drawing  made  of  a  gland 
situated  at  the  side  and  back  of  the  cervix  of  the  uterus."  In  his  work  on  the 
lymphatic  system,  Sappey  denies  the  existence  of  this  gland,  yet  in  one  of 
his  plates  (plate  xlvi.,  Fig.  9)  he  represents  a  gland  over  the  cervical  col- 
lecting trunks,  and  situated  nearly  midway  between  the  cervix  and  pelvic  wall. 

One  of  the  authors  of  this  work  has  searched  for  this  gland  in  more 
than  300  subjects  without  succeeding  in  discovering  it ;  Bruhns  on  the 
contrary,  declares  he  has  met  with  it  twice  in  eleven  subjects,  and  more 
recently,  Marcille  and  one  of  the  present  writers  have  found  it  five  times 
in  thirty  subjects  injected  by  Gerota's  method.  We  shall  shortly  see 
that  we  may  meet  with  analogous  glandular  nodules  in  the  course  of  other 
trunks  coming  from  the  cervix  of  the  uterus.  Therefore  one  or  several 
juxta-cervical  glandular  nodules  may  all  exist.  In  normal  subjects  these 
nodules  are  always  small,  and  exhibit  the  characteristics  belonging  to  the 
Schaltdriise.  In  mercury  injected  preparations,  they  easily  escape  detection ; 
injection  by  Gerota's  method  shows  them  best.  If  any  one  of  these  nodules 
hypertrophies  as  the  result  of  a  pathological  process,  the  operator  will  find 
a*  true  gland  lying  by  the  side  of  the  cervix  of  the  uterus.  This  fact  has 
been  noticed  several  times  during  the  course  of  an  hysterectomy  (Reynier). 

(b)  A  second  pedicle  (hypogastric  pedicle)  arises  from  the  same 
level  as  the   preceding,  but  passes  behind  and  below  the  ureter. 
It  is  formed  by  one  or  two  vessels,  which  are  directed  obliquely 


166  SPECIAL    STUDY    OF    THE    LYMPHATICS 

upwards,  backwards,  and  outwards,  and  terminate  in  a  gland  of 
the  hypogastric  group.  This  gland  is  usually  placed  on  the  an- 
terior terminal  trunk  of  the  hypogastric  artery,  at  the  level  of 
origin  of  the  uterine  or  vaginal  arteries. 

(c.)  A  third  pedicle  (pedicle  of  the  promontory  and  lateral  sacral  ped- 
icle) comprises  two  to  three  collecting  trunks,  which  spring  from  the 
posterior  surface  of  the  cervix,  and  at  first  descend  upon  the  vagina, 
then  run  backwards,  crossing  the  lateral  surfaces  of  the  rectum, 
and  passing  within  the  sacro-rectal  or  utero-sacral  ligaments ; 
they  then  mount  upwards  into  the  concavity  of  the  sacrum.  The 
external,  the  shorter,  are  arrested  in  the  lateral  sacral  glands ; 
the  internal,  the  longer,  pass  to  the  glands  of  the  promontory. 

As  has  been  seen  in  Fig.  56,  and  especially  in  Fig.  55,  all 
the  lymphatics  coming  from  the  neck  describe  a  series  of  con- 
centric curves,  arranged  in  different  planes.  The  external  iliac 
pedicle,  the  shortest,  is  almost  transverse ;  the  hypogastric  pedicle 
which  is  longer,  lies  in  an  oblique  plane  which  points  backward, 
and  outwards  ;  the  pedicles  of  the  lateral  sacral  and  promontory, 
still  longer,  are  entirely  sagittal. 

In  some  cases,  the  lymphatics  which  end  in  the  lateral  sacral  glands  do  not 
pursue  sucli  a  long  course  as  that  we  have  just  indicated.  They  are  arrested 
as  they  pass  under  the  peritoneum,  either  at  the  level  of  the  free  border  of 
the  utero-sacral  ligaments  or  external  to  them. 

A  lymphatic  of  the  cervix  may  pass  through  the  broad  ligament  obliquely 
and  join  the  vessels  which  constitute  the  lumbar  pedicle  of  the  body  of  the 
uterus  (this  was  found  three  times  in  thirty  subjects,  Cuneo  and  Marcille). 
This  trunk  must  not  be  confounded  with  the  vertical  juxta-uterine  anastomosis 
which  we  shall  describe  further  on. 

(2)  COLLECTING  TRUNKS  OF  THE  BODY  OF  THE  UTERUS. — The 
collecting  trunks  of  the  body  of  the  uterus  may  be  divided  into 
three  groups,  viz.  :  a  principal  and  two  accessory  groups. 

(a).  The  principal  pedicle  comprises  four  to  five  trunks,  which 
appear  beneath  the  cornu  of  the  uterus.  These  vessels  at  first  follow 
the  terminal  segment  of  the  uterine  artery,  then  pass  beneath  the 
ovary,  where  they  are  joined  by  the  vessels  coming  from  this  gland. 
They  then  run  in  the  suspensory  ligament  of  the  ovary  with  the 
ovarian  vessels,  and  ascend  towards  the  lumbar  region,  running 
round  the  blood  vessels.  Like  the  latter,  they  cross  the  ureter  on 
its  anterior  surface.  Having  arrived  at  a  spot  slightly  below  the 
hilum  of  the  kidney,  they  curve  sharply,  and  "  descend  in 
showers  "  upon  the  juxta-aortic  glands  of  the  corresponding  side. 
Some  of  them  may,  however,  end  in  the  prae-aortic  group. 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      167 


\Ve  may  find  in  the  course  of  these  vessels,  one  or  several  small  interrupting 
glandular  nodules  (Stahr,  Marcille).  They  are  comparable  to  those  de- 
scribed by  one  of  the  authors  as  lying  in  the  course  of  the  lymphatics  of  the 
testicle. 

(b)     The  two  accessor}/  pedicles  pass,  one,  to   the    external  iliac 
glands,  the  other,  to  the  inguinal  glands. 

Vena  cava .__ 


Eight  kidney  — 
Eight  venal  vein  __--- 


Right  spermatic  — 

artery 

Superior  lumbar  _ 

gland 


Inferior  lumbar 
gland 


Lymphatics  from 
body  of  uterus 


Anterior  crural 
nerve 


Peritoneum 


Lymphatics  in 
utero-sacral  lignt. 

Lymphatics  of 
cervix 


Lymphfitic-s  of 
round  lignt. 


Aorta 

Left  kidney 
Left  renal  vein 


Reno-asygo-lumb'ir 
vein 

Spermatic  artery 


i'reter 

Inferior  metenteric 

artery 
Middle  lumbar 

gland 


Middle  sacral 
artery 

Ovarian  lymphatics 
Pelvic  colon 

Lymphatics  of  Fal- 
lopian tube 

i'nl'f>r>ian  tube 
Uteru$ 

Bladder 


Fig.  57.— General  view  showing  the  lymphatics  of  the  internal  genital  organs  of  the 
female  (Poirier). 

The  primary,  which  was  observed  by  Sappey  (loc.  cit.  p.  129 
and  plate  xlvi.  Fig.  9  and  10),  and  by  Bruhns,  is  formed  by  one  to 
two  trunks,  which  take  origin  a  little  below  the  cornu  of  the 
uterus.  They  run  directly  outwards,  and  end  in  the  glands  of  the 


-    .  . 


168 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


middle  chain  of  the  external  iliac  group.  This  chain  therefore 
receives  the  lymphatics  of  the  neck  and  body  at  the  same  time. 

The  second  accessory  pedicle  as  a  rule  only  comprises  a  single 
trunk,  which  terminates  in  a  superficial  inguinal  gland  of  the 
supero-internal  group. 

These  lymphatics,  which  were  observed  by  Mascagni  (loc.  cit., 
p.  44),  are  difficult  to  inject.  Whether  mercury  or  Gerota's  solu- 
tion is  used,  it  is  rarely  that  we  can  trace  them  to  their  terminal 
glands ;  most  frequently  the  injection  is  arrested  at  the  internal 
orifice  of  the  inguinal  canal. 

The  lymphatics  of  the  neck  and  body  are  not  only  united  by 


Lymphatics 

from  the  body 

pass  ing  to 

lumbar 

glands. 


Lymphatics  of  body  and  fiindus. 
1 


Lymphatics 

from  the  body 

passing  to 

lumbar 

ijlunds. 


Lymi'hatic 
ring . 


Lymphatics 
of  cervix. 


Fig.  f>8. — Lymphatic  vessels  of  the  uterus  (Poiror). 

the  continuity  of  their  networks  of  origin,  but  also  by  a  long  ver- 
tical juxta-uterine  anastomosis  (vide  Fig.  58).  One  of  the  present 
writers  some  while  ago  described  this  anastomosis,  and  Bruhns  is 
quite  wrong  in  denying  its  existence.  In  a  fresh  series  of  researches 
we  have  again  almost  invariably  found  it  (Cuneo  and  Marcille). 

Uterine  Lymphatics  and  the  Obturator  Gland.— There  has  been  much  dis- 
cussion as  to  whether  the  lymphatics  coming  from  the  uterus  end  in  the 
gland  called  "  obturator."  We  have  already  explained  our  ideas  on 
this  gland  (vido  p.  132).  We  have  seen  that  usually  no  gland  exists  at  the 
actual  level  of  the  pelvic  orifice  of  the  obturator  foramen,  and  that  the  small 
gland  which  may  be  found  abnormally  at  this  spot  is  simply  an  interrupting 
nodule  placed  over  the  lymphatics,  the  satellites  of  the  obturator  vessels. 
The  gland  to  which  authors  alluded,  when  they  spoke  of  the  obturator  gland 
does  not  at  all  correspond  to  this  glandular  nodule,  but  clearly  does  so  to  the 
middle  gland  of  the  internal  chain  of  the  external  iliac  group,  a  gland  which 
is  placed  behind  and  below  the  obturator  foramen,  and  at  some  distance  from 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      169 

the  latter.  Does  this  gland  receive  any  lymphatics  coming  from  the  uterus  ? 
Ouveilhier  and  Lucas-Championniere  are  of  this  opinion,  and  on  this  hypothe- 
sis. A.  Guerin  rested  his  theory  of  sub-pubic  obturator  aderio-phlegmon.  Dur- 
ing the  discussion  at  the  Academy  of  Medicine  originated  by  Guerin' s 
communication,  Sappey  felt  bound  to  contradict  the  statement  that  this 
gland  receive  any  lymphatic  tributaries  from  the  uterus. 

Later  researches  by  Poirier,  Bruhns,  Peiser,  Cun6o,  and  Marcille,  etc., 
have  confirmed  Sappey' s  opinion.  The  fact  that  this  gland  may  perhaps 
be  affected  during  the  progress  of  cancer  of  the  uterus  (Malartic  and  Guillot)  is 
no  proof  at  all  that  it  directly  receives  any  uterine  lymphatics.  This  inva- 
j-i'jn  is  in  fact  easily  explained  by  the  numerous  anastomoses  which  this 
gland  effects  with  the  first  glandular  relay  of  uterine  lymphatics. 

Technique.  We  will  study  in  turn  the  injection  of  (a)  the  mucous  mem- 
brane. (6)  the  muscle,  (c)  the  uterine  peritoneum. 

(a)  Lymphatics  of  the  Mucous  Membrane. — To  see  the  lymphatics  of  the 
mucous  membrane,  a  puncture  must  be  made  in  the  region  of  the  cervix 
uteri.     The  procedure  is  as  follows  :  The  anterior  wall  of  the  cervix  is  incised, 
and  after  the  two  cut  edges  have  been  drawn  well  aside,  the  point  of  the  tube 
is  directed  against  the  median  column  of  the  posterior  wall.    When  the  opera- 
tion is  successful,  the  lymphatic  network  of  the  mucous  membrane  instant- 
ly appears   over  the  entire  length  of  the  mucous  membrane  of  the  cervix , 
and  we    see  it    becoming    continuous    below    with    that    of    the  mucous 
membrane    of    the   external    os.      While    injecting    the   lymphatics    of  the 
mucous    membrane   of  the  cervix  by    this  method,  it  often   happens  that 
we    distend    those    of  the  mucous   membrane  of    the  body.     On  the  other 
hand,  the  direct  puncture  of  this  mucous  membrane  gives  negative,  or  onlj* 
very  incomplete  results;    though  only  three  or  four  meshes    have   been  in- 
jected, ruptures  are    produced  at  many  points  in  the  lymphatic  network 
of   this  extremely  friable  mucous  membrane. 

(b)  The  Lymphatics  of  the  Muscular  Coat. — The  injection  of  the  lymphatics 
of  the  muscular  coat  is  very  easy.    If  the  uterus  has  previously  been  placed 
for  an  hour  in  water  at  40°  so  as  to  render  its  walls  normally  supple,  it  is  very 
rarely  that  we  fail  after   the  first  puncture  to  inject  all  or  a  part  of  the 
muscular  lymphatic  network.     Moreover,  as  one  of  the  present  authors  long 
since    observed,   of  all  selected    spots    it  is  here    especially  that  punctures 
yield  particularly  good  results  ;    in  this  respect,  the  cervix  and  the  uterine 
cornua  should  be  placed  in  the  first  rank.     When  mercury  is  used,  the  first 
puncture  must   be  made  under  a  pressure    of  from  20  to  30   centimetres. 
When  once  the  mercury  has  appeared  in  the  collecting  trunks,  the  pressure 
must  be  considerably  diminished  ;  unless  this  precaution  is  taken,  the  mercury 
bursts  the  vessels  at  their  exit  from  the  organ,  and  it  is  impossible  to  follow 
them  to  their  terminal  glands. 

(c)  Lymphatics  of  the  Serous  Coat.—  The  injection  of  these  vessels  is  a  much 
more  delicate  process.     We  have  succeeded  in  filling  them  by  very  super- 
ficially puncturing  the  peritoneum  which  covers  the  uterus,  and  then  intro- 
ducing the  fine  point  of  a  canula,  in  such  a  manner  that  it  penetrates  the 
subendothelial  layer,  without  reaching  the  cellular  tissue  which  unites  the 
peritoneum  to  the  uterus.     This  very  fine  network  is  easily    distinguished 
from  the  subserous  network,  which  represents  the  network  of  origin  of  the 
uterine  collecting  trunks. 

We  may  remind  ourselves  that  it  was  Mierzejewski,  and  subsequently  one 
of  the  present  authors,  who  placed  the  existence  of  this  peritoneal  network 
beyond  a  doubt. 

L 


170  SPECIAL    STUDY    OF    THE    LYMPHATICS 

To  inject  the  collecting  trunks  of  the  uterus,  it  suffices  to  press  the 
injected  material  into  the  uterine  muscle.  The  uterus  must  be  injected 
•in  situ,  especiallj'  if  Gerota's  method  is  used.  After  the  injected  portions 
have  by  this  method  been  fixed  by  formal,  or  Kaiserling's  liquid,  a  section  of 
one  half  of  the  pelvis  may  be  made,  which  much  facilitates  the  dissection 
of  the  uterine  collecting  trunks. 

BIBLIOGRAPHY. — On  account  of  their  importance  from  a  pathological  point 
of  view,  the  uterine  lymphatics  have  been  made  the  subject  of  numerous 
researches.  Previously  carried  out  with  the  object  of  determining,  if 
possible,  the  pathogeny  and  the  seat  of  peri-uterine  suppurations,  these 
researches  have  more  recently  been  undertaken  with  the  view  of  settling  which 
glands  are  affected  in  cancer  of  the  uterus.  We  will  here  confine  ourselves  to 
indicating  the  records  of  research  dealing  with  the  microscopic  anatomy  of 
the  uterine  lymphatics  ;  and  for  works  on  the  histology  of  these  vessels 
will  refer  the  reader  to  the  article  Uterus  (vide  1  vol.  v,  p.  481). 

MASCAGNI,  loc.  cit.,  p.  44  et  pi.  XIV. — SAPPEY,  loc.  cit.,  pi.  XLVI,  Fig.  9 
et  10. — LUCAS-CHAMPIONNIERE.  Les  lymphatiques  uterins  et  la  lymphangite 
uterine.  Th.  Paris,  1870. — FRIDOLIX.  Des  vaisseaux  lymphatiques  de 
1' uterus  gravide.  Militdrdrtz  Zeitschr.,  Petersbourg,  1872. — LEOPOLD. 
Lymphgefasse  des  Uterus,  Arch.  /.  Gyndkolocjie,  1789,  VI,  p.  1. — FIOUPE. 
Lymphatiques  uterins  et  parallele  entre  la  lymphangite  et  la  phlebite 
uterines.  Th.  Paris,  1876. — MIERZEJEWSKI.  Recherches  sur  les  lymphatiques 
de  la  couclie  sous-sereuse  de  1' uterus.  J.  de  V Anatomic,  1879,  p.  201. — CAXTIX. 
Th.  Paris,  18S9. — WALLTCH.  Recherches  sur  les  vaisseaux  lymphatiques 
sous-sereux  de  1'uterus  gravide  et  11011  gravide.  Th.  Paris,  1891. — POIRIER. 
Lymphatiques  des  organes  genitaux  de  la  femme.  Progres  medical,  1890,  II, 
p.  491. — AIouAV.  Kemarques  sur  les  vaisseaux  lymphatiques  des  organes 
genitaux  de  la  femme  et  leurs  anastomoses  avec  ceux  tlu  rectum,  Comptes 
rendits  Soc.  BioL,  1894,  11°  33,  p.  812. — BRUHNS.  Ueber  die  Lymphgefasse  der 
weiblichen  Genitalien  nebst  einigeii  Bermerkungen  liber  die  Topographic  der 
Leistendriisen.  Arch.  /.  Anat.  ^t.  Phys.,  Anat.  Abth.,  1898,  p.  57. — PEISER. 
Zeitschr.  /.  Gcburt.  11.  Gyndk.,  1898,  t.  XXXIX,  2e  fasc.,  p.  259. — MALARTIC 
ET  GUILLOT.  Cancer  uterin  avec  ganglion  sous-pubien.  Bull.  Soc.  Anat..  1900, 
p.  123. 

LYMPHATICS  OF  THE  VAGINA. — The  lymphatics  of  the  vagina  arise 
from  two  networks,  which  are  attached,  one  to  the  mucous  mem- 
brane, the  other  to  the  muscular  coat. 

The  network  of  the  mucous  membrane  is  extremely  rich,  and  its 
meshes  so  fine  that  the  mercury  which  runs  into  them  appears,  at 
first  sight,  to  form  a  continuous  layer  on  the  surface  of  the  mucous 
membrane  under  the  epithelium.  The  meshes  of  the  network  of 
the  muscular  coat  are  much  larger  and  formed  by  coarser  lymphatics. 
These  two  communicate  with  each  other,  and  finally  end  in  a  third 
peri-vaginal  network  from  which  the  collecting  trunks  emanate. 
All  these  collecting  trunks  pass  to  the  glands  of  the  pelvis.  This 
exclusively  pelvic  termination  of  the  vaginal  lymphatics  is  parti- 
cularly evident  in  the  infant,  where  the  hymen  clearly  indicates  the 
limits  of  the  vulva  and  vagina.  "  If  a  puncture  is  made  internal  to 

1  Treatise  of  Human  Anatomy.      Poirer  and  Charpy. 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      171 

the  hymeneal  septum,  one  of  the  present  writers  affirmed  some 
time  ago  that  the  mercury  passes  into  the  vessels  which  end  in 
the  pelvic  glands ;  if  the  external  or  vulvar  surface  of  the  septum  is 
punctured,  the  vessels  which  pass  to  the  inguinal  glands  are  injected.' 
In  the  adult  female,  it  is  possible,  if  the  inferior  part  of  the  vagina 
is  punctured,  for  the  injected  mass  to  pass  to  the  inguinal  glands, 
but  it  only  does  so  through  the  numerous  anastomoses  which  unite 


Utero->:aginal  lymphatics 
(superior  group) 


Vaginal  lymphatics      \ 


map 

M 


I  a<,mal  lymphatic,      •'• -s  jmSSS^i^g^S  / 

'     "  \  V  // 

Vaginal  lymphatics     -    — -\          1\  ^Ki^^'-'k'}'--'.'-'':-''^  '''.-. •  ,-'^   Vf  //      '/ 
(middle  group)  \        i'i  N*M§^^^PM^V/      / 

\  immimmi  \ 


wWA?^.'5-.1; 


affig 


rSs!wS 


;---;-- 


£•$> 


^: 

/;l 

Vaginal  lymphatics /      '^ 

(inferior  group)  f 

Lymphatics  of  valva  • 


'J&£f*f£K 

&i~zK,*:'i 


^5] 


« 


-^^ 
$& 


Fig.  59. — Lymphatic  network  of  the  mucous  membrane  of  the  vagina  with  their  efferent 
trunks  (Poirier). 

the  vaginal  to  the  vulvar  network,  and  not  by  direct  collecting 
trunks. 

But,  though  all  the  vaginal  collecting  trunks  pass  to  the  pelvic 
glands,  we  may,  by  taking  their  origin,  course,  and  termination,  as 
the  basis  of  our  scheme  divide  them  into  three  groups  :  superior, 
middle  and  inferior. 

(a)  The  Superior  Group. — The  superior  lymphatics  arise  from  the 
vaginal  culs  de  sac,  and  are  responsible  for  the  lymphatic  circu- 
lation of  the  upper  third  of  the  vagina.  There  are  usually  two  trunks 


172 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


on  either  side.  One  which  springs  from  the  anterior  cul  desac,  runs 
upwards  and  outwards,  passes  in  front  of  the  ureter,  then,  embracing 
several  of  the  trunks  corning  from  the  cervix,  terminates  with  the 
latter  in  the  middle,  gland  of  the  middle  chain  of  the  external  iliac 
group.  The  other  which  comes  from  the  posterior  cul  de  sac  also  runs 
upwards  and  outwards  and  terminates  either  in  the  preceding  gland, 
or  in  the  posterior  gland  of  the  same  chain  (a  and  b,  Fig.  60). 


Fig.  60.— The  lymphatics  of  the  vagina  (semi-diagrammatic)  (Cunco  and  Marcille). 

a,  b.  External  iliac  glands  (middle  chain),  c.  Transverse  external  iliac  pedicle,  d.  Gland 

of  the  promontory,  e.  Lateral  sacral  gland.  /.  Hypogastric  gland,  g.  Hypogastric  'pedicle. 
h.  Retro-vaginal  glandular  nodules. 

(b)  The  Middle  Group. — The  lymphatics  of  this  group  come  from 
the  middle  third  of  the  vagina.  They  are  satellites  of  the  vaginal 
artery,  and  like  this  vessel,  run  obliquely  upwards,  backwards  and 
outwards,  and  end  in  a  gland  of  the  hypogastric  group,  placed  at 
the  actual  origin  of  the  vaginal  artery.  These  lymphatics  and  the 
glands  in  which  they  end  are  contained  in  the  hypogastric  space. 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      173 

(c)  The  Inferior  Group.— The  collecting  trunks  of  this  group 
appear  at  the  lower  .third  of  the  recto- vaginal  septum.  At  first 
descending,  they  then  run  outwards,  then  directly  backwards,  passing 
between  the  rectum  and  the  sacro-recto-genital  aponeurosis.  They 
then  pass  upwards  into  the  concavity  of  the  sacrum,  internal  to  the 
anterior  sacral  foramina,  and  terminate  in  the  glands  of  the  group 
of  the  promontory,  or  more  rarely  in  a  lateral  sacral  gland. 


Ovary 
Fallopian  tube 


Fig.  01.— Lymphatic  vessels  of  the  middle  third  of  the  vagina  and  the  glands  in 
which  they  end  (Poirier). 

We  may  find  some  small  interrupting  glandular  nodules  lying  011  these 
different  collectors,  and  in  the  case  of  the  middle  and  inferior  collectors  they 
are  constant.  Some  of  them  are  even  placed  between  the  layers  of  the 
recto  ^agmal  septum.  One  of  the  authors  pointed  them  out  a  long  time  ago, 
and  our  recent  researches  with  Marcille's  assistance  have  shown  us  that  we 
may  regard  them  as  constant. 

To  sum  up,  the  lymphatics  of  the  vagina  run  to  the  pelvic  glands 
in  three  groups  of  collecting  trunks  :  (a)  A  superior  transverse  group, 
ending  in  the  middle  chain  of  the  external  iliac  glands  ;  (b)  a  middle 
group. which  passes  obliquely  upwards  and  backwards,  and  terminates 


174  SPECIAL    STUDY    OF    THE    LYMPHATICS 

in  the  hypogastric  glands  ;  (c)  an  inferior  sagittal  group,  which  runs 
in  front  of  the  sacrum  and  ends  in  the  glands  of  the  promontory. 

ANASTOMOSES. — The  lymphatics  of  the  vagina  anastomose  above, 
with  those  of  the  cervix  uteri,  and  below,  with  those  of  the  vulva, 
owing  to  the  continuity  of  their  networks  of  origin.  Behind,  they 
communicate  with  the  lymphatics  of  the  rectum  ;  Morau  affirms  that 
certain  vessels  which  come  from  the  anterior  wall  of  the  rectum  join 
the  collecting  trunks  which  run  in  curves  over  the  posterior  surface 
of  the  vagina  ;  but  to  us,  on  the  contrary,  it  seems  that  there  is  an 
absolute  independence  between  the  lymphatics  of  the  vagina  and 
those  of  the  bladder. 

Technique. — One  of  the  present  writers  has  laid  clown  the  following  rules  for 
the  injection  by  mercury  of  the  lymphatics  of  the  vagina.  "  The  organ  must 
remain  in  situ  and  its  normal  relations  preserved  as  far  as  possible.  To  effect 
this,  after  detaching  all  the  soft  parts  which  form  the  anterior  wall  of  the 
hypogastric  and  pubic  regions,  we  make  four  saw  cuts,  passing  through  the 
horizontal  rami  of  the  pubes,  the  ascending  rami  of  the  ischium.  and  all  the 
anterior  part  of  the  pelvic  girdle  :  then  seizing  the  bladder  with  forceps,  this 
organ  together  with  the  urethra  is  carefully  separated  from  the  anterior 
vaginal  wall.  The  anterior  wall  of  the  vagina  and  uterus  are  thus  preserved 
intact  in  front.  By  the  aid  of  scissors  with  rounded  extremities,  we  next 
incise  the  anterior  wall  of  the  vagina  in  the  middle  line,  keeping  to  the  antero- 
posterior  axis,  from  the  bulb  of  the  vagina  to  its  insertion  into  the  cervix. 
To  avoid  the  escape  of  mercury  through  the  numerous  lymphatics  opened  by 
this  incision,  I  think  it  advisable  to  place  oil  the  lips  of  the  incision  a  red  hot 
stylet  or  the  blade  of  a  thermo-cautery.  It  is  advantageous  also,  before  pro- 
ceeding with  the  injection,  to  thoroughly  cleanse  the  mucous  membrane  of  tho 
vagina  with  a  somewhat  coarse  cloth,  to  remove  the  layers  of  epithelium 
which  cover  it.  Without  this  precaution  we  run  the  risk  of  blocking  the 
mouth  of  the  injection  tube  by  the  first  puncture.  Should  this  occur,  another 
attempt  must  be  made  higher  up,  or  at  the  side.  The  pressure  necessary  to 
effect  a  successful  injection  varies  in  different  subjects  :  in  infants,  unly  a  very 
low  pressure  (8  to  10  centimetres  of  mercury)  is  required,  but  in  the  adult,  it 
often  has  to  be  raised.  To  inject  the  network  of  the  mucous  membrane,  the 
puncture  ought  to  be  made  very  superficially,  but  more  deeply  for  that  of 
the  muscular  coat.  Sometimes,  especially  in  the  infant,  a  single  puncture 
is  sufficient  to  inject  all  the  vagina  ;  but  to  make  a  complete  injection,  two 
or  three  punctures  at  different  points  are  usually  necessary  :  In  these  cases, 
it  is  necessary  to  seal  up  the  apertures  made  by  the  preceding  punctures  by 
lightly  cauterizing  with  the  red  hot  end  of  a  stylet.  If  one  or  several 
punctures  produce  110  result,  the  experiment  must  be  repeated  until  the  mer- 
cury is  seen  to  spread  into  and  invade  the  lymphatic  network  wit);  its  well 
known  rapidity  ;  the  pressure  must  now  be  diminished  and,  if  the  sides  of  ilie 
vagina  are  carefully  watched,  one  or  two  strands  of  mercury  will  be  seen  to 
shoot  over  its  lateral  portions  and  pass  to  the  glands.  During  the  injection, 
two  or  three  trunks  opened  by  the  scalpel  while  detaching  the  bladder,  will 
cause  some  leakage,  but  this  can  easily  be  arrested  by  some  light  cauteri- 
zations." The  injection  of  the  lymphatics  of  the  vagina  by  Gerota's  method 
may  be  effected  by  a  similar  process. 

BIBLIOGRAPHY. — Vide  UTERUS,  pp.   166,  167  and  168. 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      175 

4.    LYMPHATICS  OF  THE  URINARY  PASSAGES. 

LYMPHATICS  OF  THE  URETHRA. — We  will  now  study  the  lym- 
phatics of  the  urethra  in  the  male  and  in  the  female. 

I.  IN  THE  MALE. — The  lymphatics  of  the  urethra  arise  from,  a  net- 
work attached  to  the  mucous  membrane  of  the  urethra.  The  arrange- 
ment of  this  network  of  origin  has  been  perfectly  described  by  Sappey. 
"  The  lymphatic  vessels  of  the  mucous  membrane  of  the  urethra 
cover  all  its  free  surface,  from  the  prostatic  utricle  to  the  meatus 
urinarius.  Posteriorly,  the  network  formed  by  these  vessels  and  by 
the  anastomoses  which  unite  them,  is  continued  on  to  theejaculatory 


Fig  02.— Lymphatics  of  the  penile  and  membranous  portion  of  the  urethra  (Cuneo 
and  Marcille). 

abed.  External  iliac  glands,  e.  Penile  proe-symphysian  collecting  trunk.  /,  g.  Satellite 
trunk  of  internal  pudic  vessels.  *.  Collecting  trunk  coming  from  the  anterior  surface  of 
the  nrostate.  t.  Penile  retro-symphysian  collecting  trunk. 


176  SPECIAL    STUDY    OF    THE    LYMPHATICS 

ducts,  and  is  thus  continuous  with  that  of  the  vesiculae  seminales  and 
the  vasa  deferentia.  In  front,  it  is  continuous  with  the  tortuous 
branchlets  on  the  surface  of  the  gland.  This  network  has  an  excep- 
tional arrangement ;  the  larger  and  smaller  branches  which  form  it, 
follow  the  direction  of  the  urethral  Avails.  By  many  transverse  and 
oblique  anastomoses,  they  unite  very  frequently  and  are  grouped  in 
parallel  and  unequal  bundles,  separated  by  longitudinal  ridges." 
(Sappey). 

From  this  network  emanate  several  collecting  trunks   which  may 
be  divided  into  four  groups  : 

1.  The  only  collecting  trunks  which  Sappey  mentions  are  those 
ivliich  come  from  the  mucous  membrane  covering  the  glans.     They  tra- 
verse the  inferior  wall  of  the  urethra  at  the  level  of  the  f raenum,  unite 
with  the  lymphatic  trunks  coming  from  the  glans,  and  terminate  in 
the  same  manner  as  those  vessels  (vide  Fig.  52  and  p.  157). 

2.  The  collecting  trunks  which  come  from  the  remainder  of  the 
penile  portion  vary  in  number.     They  emerge  on  the  inferior  surface 
of  the  penis,  turn  round  the  lateral  surfaces  of  the  corpora  cavernosa 
and  unite  with  the  trunks  coming  from  the  glandular  portion.     The 
majority  run  and  terminate  in  the  same  way  as  the  latter,  but  some 
take  an  entirely  different  course  ;  for  instance,  one  of  these  vessels 
passes  over  the  symphysis,  runs  between  the  two  recti  muscles, 
then  turns  directly  to  the  left  and  terminates  in  the  internal  retro- 
crural  gland.    More  rarely,  it  may  be  found  to  terminate  in  the  middle 
gland  of  the  internal  chain  of  the  external  iliac  glands.     Kiittner  was 
the  first  to  note  the  presence  of  this  vessel,  but  he  was  wrong  in 
believing  that  it  came  from  the  mucous  membrane  of  the  glans.     A 
second  collector  passes  underneath  the  symphysis  and  unites  with 
the  vessels  coming  from  the  bulbar  and  membranous  portions  of  the 
urethra. 

3.  The  lymphatics  of  the  bulbar  and  membranous  portions  end  in 
the  following  three  systems  of  collecting  trunks  : 

(a)  One  of  these  vessels  makes  its  appearance  on  the  upper  sur- 
face of  the  bulb  in  the  angle  formed  by  the  divergence  of  the  two 
corpora  cavernosa.     It  embraces  either  the  transverse  artery  of  the 
bulb,  or  the  artery  to  the  corpus  cavernosum,  it  then  becomes  a 
satellite  of  the  trunk  of  the  internal  pudic  artery  and  terminates  in  the 
gland  attached  to  the  intra-pelvic  portion  of  the  trunk  of  this  artery. 

(b)  A  second  vessel  runs  towards  the  posterior  surface  of  the  sym- 
physis, and  then  behind  the  pubes  to  terminate  in  the  internal  retro- 
crural  gland. 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      177 

(c)  A  third  trunk  ascends  on  the  anterior  surface  of  the  bladder, 
and  unites  with  the  trunks  coming  from  the  inferior  segment  of 
this  surface,  and  terminates  with  the  latter  in  the  middle  gland  of  the 
internal  chain  of  the  external  iliac  glands. 

4.  The  lymphatics  of  the  proslatic  portion  pass  into  the  collecting 
trunks  which  emerge  from  the  glandular  parenchyma. 

The  injection  of  the  lymphatics  of  the  urethra  is  a  delicate  process,  and  it 
is  rather  difficult  to  follow  the  somewhat  complicated  course  of  their  collecting 
trunks.  Sappey  only  mentions  the  vessels  coming  from  the  glandular  portion  of 
the  urethra.  More  recently,  Kiittner  incidentally  mentions  several  other  collect- 
ing trunks.  The  description  we  have  just  given  is  founded  on  the  researches 
carried  out  by  one  of  the  present  writers  with  the  assistance  of  Marcille.  It 
makes  no  pretence  at  being  final.  We  ought  to  remark  that  some  of  the 
collecting  trunks  whose  course  we  have  described  have  only  been  met  with 
in  certain  subjects,  in  spite  of  the  considerable  number  of  specimens  we  have 
injected.  It  is  therefore  difficult  to  say  whether  this  inconstancy  is  real,  or 
whether  it  is  caused  by  the  difficulties  of  injecting  these  vessels. 

SAPPEY,  loc.  cit.,  p.  53  et  pi.  VII,  Fig.  7. — KCTTNER,  Zur  Verbreitung  und 
Prognose  des  Penis-carcinoms.  Arch.  /.  klin  Chir.,  1899,  LIX,  1,  p.  180. 

II.  Ix  THE  FEMALE. — The  lymphatics  of  the  urethra  of  the  female 
have  a  precisely  similar  arrangement  to  that  of  the  lymphatics  of  the 
membranous  and  prostatic  portions  in  the  male.  They  therefore 
end  in  the  middle  and  internal  chains  of  the  external  iliac  glands,  in 
the  hypogastric  glands,  and  in  the  glands  of  the  promontory. 

LYMPHATICS  OF  THE  PROSTATE. — The  lymphatics  of  the  pros- 
tate arise  by  fine  capillaries  arranged  in  the  form  of  a  network  round 
each  glandular  acinus.  From  these  periacinous  networks,  run  larger 
vessels  which  pass  towards  the  periphery  of  the  gland,  and  form  at 
its  surface  a  second  network — the  periprostatic  network,  from  which 
the  collectors  start.  The  latter,  which  are  symmetrically  arranged 
on  each  side  of  the  gland  may  run  in  four  different  directions  : 

1.  A  primary  trunk  (a,  Fig.  63)  starts  from  the  posterior  surface 
of  the  prostate,  and  runs  on  to  the  bladder  in  the  triangle  between 
the  vasa  deferentia.  It  ascends  as  far  as  the  middle  part  of  the 
postero-superior  surface  of  the  bladder,  where  it  curves  sharply  out- 
wards, crosses  the  hypogastric  artery,  and  terminates  in  the  middle 
gland  of  the  middle  chain  of  the  external  iliac  group  (vide  p.  131). 
In  its  retro-vesical  course,  this  trunk  describes  numerous  curves  ; 
it  may  pass  through  some  small  interrupting  glandular  nodules 
(Schaltdriisen),  close  to  the  spot  where  it  crosses  the  hypogastric 
artery.  This  ascending  channel  frequently  consists  of  two  trunks 
which  then  terminate  in  the  middle  and  superior  glands  of  the 
middle  chain. 


178 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


2.  A  second  collector,  arising  like  the  preceding  from  the  posterior 
surface  of  the  prostate,  accompanies  the  prostatic  artery.  Like  the 
latter,  it  runs  upwards,  outwards  and  backwards,  and  terminates  in 
one  of  the  middle  glands  of  the  hypogastric  group.  In  the  neighbour- 


FIG.  63.— Lymphatics  of  the  prostate  (Cuneo  and  Maicille). 

a,  6.  External  iliac  glands,  c.  External  iliac  prostatic  pedicle,  d.  Retro-prostatic  glan- 
dular nodules,  e.  Prostatic  pedicle  of  the  promontory.  /.  Gland  of  the  promontory. 
g.  Latero-sacral  gland,  h.  Middle  haemorrhoidal  gland,  t.  Middle  haemorrhoidal  trunks. 

hood  of  the  prostatic  origin  of  this  trunk,  two  or  three  small  glandular 
nodules  are  almost  constantly  found. 

3.  Two  or  three  other  collecting  trunks  also  start  from  the  pos- 
terior surface  of  the  gland,  and  run  at  first  downwards,  and  then 
backwards.  Tboy  enter  the  sacro-recto-genital  aponeurosis,  cross 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      179 

the  lateral  surfaces  of  the  rectum,  and  then  ascend  on  the  anterior 
surface  of  the  sacrum.  They  do  not  all  terminate  in  the  same 
manner.  The  shorter  and  more  external  (b,  Fig.  63)  end  in  the 
lateral  sacral  glands  which,  as  we  have  already  seen,  are  usually 
situated  internal  to  the  second  sacral  foramina.  The  longer  and 
more  internal  (e,  Fig.  63)  pass  as  far  as  the  promontory  to  terminate 
in  the  glands  situated  there. 

4.  Finally,  from  the  anterior  surface  of  the  prostate  may  be  seen 
a  descending  trunk  which  runs  towards  the  pelvic  floor,  where  it 
unites  with  the  vessels  coming  from  the  membranous  portion  of  the 
urethra.  In  company  with  the  latter,  it  embraces  the  artery  of  the 
corpus  spongiosum,  and  then  runs  with  the  internal  pudic  ;  it 
finally  terminates  in  a  gland  of  the  hypogastric  group,  situated  on 
the  intra-pelvic  portion  of  the  trunk  of  the  internal  pudic  artery. 
This  descending  prostatic  channel,  which  was  observed  in  the  dog  by 
Walker,  has  also  been  found  in  man  by  Marcille  (three  times  in  fifteen 
subjects). 

The  lymphatics  of  the  prostate  to  which  little  attention  was  given  by 
Mascagni,  were  for  the  first  time  described  in  some  detail  by  Sappey  in  1854  ; 
but  this  author  hardly  described  in  sufficient  detail  the  course  and  termina- 
tion of  the  prostatic  collecting  trunks.  In  1899,  Walker  undertook  the 
study  of  these  vessels  in  the  dog  and  in  the  monkey  ;  and  quite  recently, 
Cuiieo  and  Marcille  have  systematized  the  arrangement  of  the  prostatic 
lymphatics  in  man. 

BIBLIOGRAPHY. — MASCAGNI,  loc.  cit.,  p.  44  et  tab.  XII,  Fig.  2. — SAPPEY, 
loc.  cit.,  p.  134,  pi.  XL VIII,  Fig.  4,  et  Recherches  sur  la  conformation  de  Vuretre. 
Paris,  1854,  p.  84. — WALKER.  Ueber  die  Lymphgefasse  der  Prostata  beim 
Hunde,  Arch,  jur  Anat.  u.  Physiol,  Annt.  Abth.,  1899,  1  et  2,  p.  1  a  10.— 
STAHR.  Bemerkungen  liber  die  Verbindungen  der  Lymphgefasse  der  Prostata 
mit  denen  der  Blase.  An.  Anz.,  1899,  11°  1,  p.  27-29. — CUN  o  et  MARCILLE. 
Note  sur  les  collecteurs  lymphatiques  de  la  prostate.  Communication  a  la 
Soc.  anat.j  31  Janvier  1902. 

THE  LYMPHATICS  OF  THE  BLADDER. — The  origin  of  the  vesical 
lymphatics  will  be  studied  further  on  (vide  vol.  v.  p.  123  l).  Here 
we  need  only  observe  that  the  trend  of  modern  scientists  is  to  deny  the 
existence  of  absorbent  vessels  in  the  vesical  mucous  membrane,  and 
to  maintain  that  the  only  network  of  origin  which  exists  in  the  blad- 
der is  an  intramuscular  one.  The  emergent  vessels  of  this  network 
end  in  a  second  network  placed  on  the  outer  surface  of  the  vesical 
muscle,  under  the  peritoneum  or  the  umbilico-praevesical  fascia. 

The  course  and  termination  of  the  collectors  of  this  network  vary 
according  to  their  situation  on  the  anterior  or  posterior  surface  of 
the  bladder. 

1  Treatise  of  Human  Ana'omy.     Poirier  and  Charpy. 


180  SPECIAL    STUDY    OF    THE    LYMPHATICS 


FIG.  64. — Lymphatics  of  the  bladder  in  the  new-born  infant  (Cuneo  and  Marcille). 

a.  External  iliac  gland  (external  chain).  6.  External  iliac  gland  (middle  chain),  c.  Ex- 
ternal iliac  gland  (internal  chain),  d.  Deep  inguinal  glands,  c.  Left  juxta-aortie  gland. 
/.  Gland  of  the  promontory,  g.  Lateral  vesical  glands,  h.  Praevesical  glands. 

1.  Anterior  Surface. — The  collecting  trunks  coming  from  the  an- 
terior  surface  form   two   groups.       The  trunks  coming  from  the 
inferior  segment  of  this  surface  run  almost  transversely  outwards; 
and  pass  into  a  gland  placed  on  the  lateral  surface  of  the  pelvic 
cavity,  between  the  external  iliac   vein  and   the  obturator  nerve, 
a  few  millimetres  behind  the  crural  ring.     The  trunks  which  come 
from  the  superior  part  of  the  anterior  surface  are  remarkable  for 
their  sinuosities.     They  run  upwards  and  outwards,  cross  the  hypo- 
gastric  artery,  passing  either  above,  or  more  frequently  below  it,  and 
eventually  terminate  in  the  middle  gland  of  the  middle  chain  of  the 
external  iliac  group.     In  the  course  of  these  lymphatic  trunks  are 
placed  small  glands,  which  are  only  visible  after  injection  :  they 
belong  to  the  group  of  interrupting  glandular  nodules  (vide  p.  86). 
Some  of  these  glands  are  placed  in  front  of  the  bladder  (praevesical 
glands) ;  they  may  become  hypertrophied  in  certain  pathological  con- 
ditions (Bazy),  and  may  form  the  starting  point  of  certain  prae- 
vesical phlegmons.     Others  are  placed  at  the  spot  where  the  lym- 
phatic   vessels   cross  the  hypogastric  artery  (latero-vesical  glands. 
Waldeyer,  Gerota). 

2.  Posterior  Surface. — The  trunks  which  come  from  the  posterior 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      181 

surface  also  form  several  groups,  (a)  The  trunks  which  come  from 
the  superior  portion  of  this  surface,  run  outwards  describing  several 
curves.  They  cross  the  hypogastric  artery,  where  they  traverse  some 
small  lateral-vesical  glands,  and  terminate  in  the  external  iliac  gland 
in  which,  as  we  have  seen,  the  superior  lymphatics  of  the  anterior 


Fia.  65.-  Lymphatics  of  the  bladder  (Cuneo  and  Marcille). 

a.  Gland  of  the  external  chain  of  the  external  iliac  group,  b,  b.  Collecting  trunk  of  the 
upper  portion  of  the  posterior  surface,  c.  Collecting  trunk  of  the  inferior  portion  of  the 
anterior  surface,  d.  Gland  of  the  promontory,  e.  Hypogastric  gland,  situated  on  the  gluteal 
artery.  /.  The  hypogastric  gland,  g.  Satellite  collecting  trunks  of  the  inferior  vesical  artery. 
h.  Collecting  trunks  about  to  end  in  the  glands  of  the  promontory. 

surface  also  end.  (b,  Fig.  65).  (b)  Other  trunks  pass  backwards 
following  the  course  of  the  hypogastric  artery,  and  end  in  a  gland 
which  is  situated,  like  the  preceding,  on  the  external  iliac  vein,  but 
more  posterior  to  it,  immediately  in  front  of  the  bifurcation  of  the 
common  iliac  artery,  (c)  Other  trunks  which  come  from  the  middle 

M  * 


182  SPECIAL    STUDY    OF    THE    LYMPHATICS 

segment  of  the  posterior  surface,  end  in  the  hypogastric  glands 
(<7,  Fig.  65).  (d)  Others  finally  arising  from  near  the  neck  of  the  bladder 
run  directly  backwards,  and  crossing  the  lateral  surfaces  of  the 
rectum,  ascend  on  to  the  anterior  surface  of  the  sacrum  and  ter- 
minate in  the  glands  situated  in  the  angle  of  bifurcation  of  the 
abdominal  aorta,  in  front  of  the  promontory  (7i,  Fig.  65). 

To  sum  up,  the  vesical  lymphatics  end  in  the  external  iliac  glands, 
in  the  hypogastric  glands,  and  in  the  glands  of  the  bifurcation  of 
the  aorta.  We  may  add  that  the  praevesical  network  is  continuous 
with  the  network  which  surrounds  the  prostate,  the  vesiculae  sem- 
inales,  the  vasa  deferentia,  and  the  terminal  parts  of  the  ureters. 

Historical  and  Technical. — The  lymphatics  of  the  bladder  have  given  rise  to 
numerous  researches.  We  will  not  here  recall  the  discussions  to  which 
the  question  of  the  existence  of  these  lymphatics  has  given  rise  ;  they  will  be 
found  summarized  in  the  excellent  monograph  of  Pasteau.  As  regards  the 
arrangement  of  the  collecting  trunks  and  the  situation  of  their  terminal  glands, 
we  find  but  very  incomplete  descriptions  given  in  the  classical  works.  Mas- 
cagni  and  Cruikshank,  however,  appear  to  have  observed  the  lateral  vesical 
glands.  Sappey  does  not  mention  them,  and  wrongly  concluded  that  the 
lymphatics  of  the  bladder  terminate  exclusively  in  the  external  iliac  glands. 
Pasteau  publishes  no  original  work,  and  confines  himself  to  summarising 
previous  researches.  It  is  only  in  recent  times,  that  Gerota,  and  more  re- 
cently, Marcille  and  one  of  the  present  authors  demonstrated  the  topography 
of  the  lymphatic  glandular  apparatus  connected  with  the  bladder. 

The  reason  why  anatomical  literature  only  furnishes  us  with  such  vague 
information  on  this  point  is  that,  the  injection  of  the  vesical  lymphatics  is  a 
somewhat  difficult  process.  With  mercury,  we  have  only  exceptionally  suc- 
ceeded in  injecting  them,  but  with  Gerota's  method  they  are  shown  much  more 
readily.  Again,  certain  rules  must  be  carefully  observed.  It  is  useless  to 
try  and  inject  the  perimuscular  network,  for  this  almost  invariably  results 
in  the  production  of  an  extensive  extravasation.  The  canula  must  be  inserted 
into  the  actual  thickness  of  the  vesical  muscle,  and  the  injected  mass  must  be 
pressed  if  possible  into  the  intramuscular  network  (Cuneo  and  Marcille). 

BIBLIOGRAPHY.  —  CRUIKSHANK,  loc.  cit.,  p.  304. — MASCAGNI,  loc.  cit., 
p.  44  et  tabl.  XII,  Fig.  11.— SAPPEY,  loc.  cit.,  p.  304.— GEROTA.  Ueber 
Anatomie  und  Physiologie  der  Harnblase.  Arch.  f.  Anat.  u.  Phijsiol.,  Phys. 
Abth.,  1897,  p.  428.— GEROTA.  Ueber  die  Lymphgefasse  und  die  Lymph- 
drusen  der  Nabelgegend  und  der  Harnblase,  An.  Anz.,  XII,  4  et  5,  p.  89.— 
PASTEAU.  Etat  du  systeme  lymphatique  dans  les  maladies  de  la  vessie  et  de 
la  prostate.  Th.  Paris,  1878  (contient  une  bibliographic  tres  complete). — 
WALKER.  Ueber  die  Lymphgefasse  der  Prostata  beim  Hunde.  Arch.  /.  Anat. 
u.  Physiol.,  Anat.  Abth.,  1899,  1  et  2,  p.  1  a  10.— CUNEO  et  MARCILLE. 
Lymphatiques  de  la  vessie.  Communic.  Soc.  anat.,  29  novembre  1901. — 
BAZY,  Rapport  sur  une  note  de  Gerota.  Soc.  Chirurgie,  7  mai  1902. 

LYMPHATICS  OF  THE  URETER.— Our  knowledge  of  the  lymphatics 
of  the  ureter  is  still  imperfect.  Sappey  was  only  able  to  inject  them 
in  the  horse,  and  only  met  with  them  in  the  muscular  coat.  In  the 
course  of  our  injections  of  the  vesical  lymphatics,  we  have  several 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      183 


times  seen  the  subserous  network  of  the  bladder  extend  itself  a  few 
millimetres  round  the  ureter.  The  lymphatics  of  the  ureter  end  in 
multiple  collecting  trunks  which  pass  to  the  neighbouring  glands. 

LYMPHATICS  OF  THE  KIDNEYS. — The  lymphatics  of  the  kidneys 
arise  from  two  networks,  one  superficial,  and  the  other  deep. 

The  superficial  network,  which  was  observed  by  Mascagni,  has 
not  been  seen  by  Ludwig  and  Kolliker.  The  now  classical 


Capsular  artery 
a 

Renal  artery 
Spermatic  artery 


nal  vein 


Left  spermatic 
vein 


FIG.  66. — Lymphatics  of  the  kidneys. 

a/ Right  juxta-aortic  gland  (retro -venous).     6.  Prae-aortic  gland,     c.  Right  juxta-aortic 
gland  (praevenous).     d.  Left  juxta-aortic  gland. 

researches  of  Teichmann  and  Sappey,  and  the  more  recent  works 
of  Renaut  and  Stahr,  however,  leave  no  doubt  as  to  its  existence  ; 
but  it  is  extremely  difficult  to  inject.  Immediately  underneath  the 
capsule,  it  is  remarkable  for  the  tenuity  of  its  meshes.  From  this 
network,  two  systems  of  collecting  trunks  arise  which,  following 
Sappey,  we  may  divide  into  convergent  and  divergent.  The  con- 
vergent empty  themselves  into  the  collecting  trunks  of  the  deep 
network,  either  by  immediately  sinking  into  the  depth  of  the  kidney, 
or  by  running  under  the  capsule  only,  to  join  the  deep  collecting 


184  SPECIAL    STUDY    OF    THE    LYMPHATICS 

trunks  near  the  hilum.  The  divergent  trunks  perforate  the  fibrous 
capsule,  and  pass  into  the  network  which  we  shall  describe  further 
on  when  dealing  with  the  fatty  capsule  of  the  kidney. 

The  arrangement  of  the  deep  network  has  given  rise  to  several 
discussions  into  which  we  need  not  enter  here  (vide1  vol.  v.  pp.  49, 
50).  It  eventually  gives  origin  to  large  collecting  trunks,  varying 
in  number  from  four  to  seven,  which  leave  the  kidney  at  the  hilum. 
These  trunks  course  round  the  artery  and  the  renal  vein.  They 
are  usually  satellites  of  the  vein,  some  running  on  its  anterior,  and 
some  on  its  posterior  surface. 

The  classical  authors  have  only  given  us  somewhat  vague  informa- 
tion as  to  the  mode  of  termination  of  these  vessels,  simply  stating 
that  these  lymphatics  terminate  in  the  glands  of  the  hilum,  which 
moreover  is  incorrect. 

In  his  recent  monograph  on  the  lymphatics  of  the  kidney,  Stahr, 
who  was  much  struck  by  the  variations  shown  in  different  subjects, 
declares  that  he  finds  it  impossible  to  formulate  a  general  scheme  for 
their  mode  of  termination.  After  examining  sixteen  kidneys  injected 
by  Gerota's  method,  we  have  arrived  at  the  following  conclusions  : 

The  mode  of  termination  of  the  renal  lymphatics  varies  on  the 
two  sides.  On  ike  right,  we  may  divide  the  vessels  into  anterior 
and  posterior.  The  anterior  trunks  run  in  front  of  the  renal  vein, 
and  pass  downwards  and  inwards  and  terminate  in  the  prae- venous 
mass  of  right  j uxta-aortic  glands  (vide  p.  139).  They  usually 
terminate  in  the  group  of  the  above-mentioned  glands,  which  is 
situated  on  the  anterior  surface  of  the  vena  cava,  immediately  below 
the  opening  of  the  renal  veins  into  the  inferior  cava,  but  one  of  them 
may  often  be  seen  to  end  in  a  gland  belonging  to  the  same  group, 
placed  much  lower  down,  close  to  the  bifurcation  of  the  aorta.  It  is 
equally  common  to  see  one  of  these  trunks  end  in  a  gland  of  the  prae- 
aortic  group.  The  posterior  trunks  are  shorter  than  the  preceding, 
and  are  placed  behind  the  vein  and  renal  arteries.  They  terminate 
in  two  or  three  large  glands  situated  behind  the  inferior  vena  cava, 
in  front  of  the  right  pillar  of  the  diaphragm.  These  glands  belong 
to  the  retro- venous  group  of  the  right  j  uxta-aortic  glands.  Their 
efferent  vessels  pass  through  the  right  pillar  of  the  diaphragm, 
traversing  it  through  the  same  orifice  as  the  great  splanchnic  nerve, 
and  terminate  in  the  thoracic  duct.  On  the  left,  the  collecting 
trunks,  which  leave  the  kidney  at  the  hilum,  terminate  in  four  or 
five  glands  which  belong  to  the  j  uxta-aortic  group  of  the  correspond- 
1  Treatise  of  Human  Anatomy.  Poirier  and  Charpy. 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      185 

ing  side,  which  are  thus  ranged  on  the  left  side  of  the  abdominal 
aorta.  The  highest  of  these  glands  are  situated  in  front  of  the  left 
pillar  of  the  diaphragm,  through  which  their  efferent  vessels  pass 
on  their  way  to  join  the  thoracic  duct  (vide  Fig.  66). 

To  sum  up,  the  lymphatics  of  the  kidneys  end  principally  in  the 
juxta-aortic  glands  of  the  corresponding  side,  and  accessorily  in 
the  prae-aortic  glands.  In  any  case,  it  is,  if  not  absolutely  incorrect, 
at  least  insufficient,  to  state  that  the  lymphatics  of  the  kidney 
terminate  in  the  glands  placed  at  the  level  of  the  hilum  of  these 
organs.  At  the  level  of  the  hilum,  however,  we  may  meet  with 
some  small  glandular  nodules,  but  by  reason  of  their  contiguity  and 
their  small  size,  they  should  be  regarded  as  belonging  to  that  variety 
of  gland  which  we  have  described  above  as  the  interrupting  glandular 
nodule  (Schaltdriisen),  and  which  it  is  important  to  distinguish  from 
the  regional  glands  which  are  much  more  constant  in  their  presence 
and  situation  (Stahr).  One  of  these  nodules  is,  however,  distinguish- 
able by  its  relative  frequency  and  by  its  fairly  constant  situation 
beneath  the  right  renal  vein,  in  the  angle  which  this  vessel  forms 
with  the  inferior  vena  cava. 

The  fatty  capsule  of  the,  kidney  possesses  a  rich  lymphatic  network, 
which  has  recently  been  well  described  by  Stahr.  The  efferents  of 
this  network  end  in  the  same  glands  as  the  collectors  from  the 
kidney  itself.  The  network  of  the  fatty  capsule  communicates, 
as  we  have  seen,  with  the  lymphatics  of  the  kidney  :  and  it  is  not 
rare  to  find,  during  the  progress  of  epithelial  cancers  of  this  organ, 
lines  of  new  growth  in  the  fatty  capsule. 

Technique. — The  injection  of  the  superficial  lymphatics  of  the  kidney  is 
extremely  difficult,  whatever  method  is  employed.  To  show  the  deep  lym- 
phatics, Sappey  advises  that  a  current  of  water  be  passed  through  the  renal 
artery.  The  water  returns  at  once  by  the  vein  and  by  the  lymphatics  which 
are  then  rendered  very  apparent.  We  have  always  injected  these  vessels  with 
the  greatest  ease  by  Gerota's  method.  All  that  is  required  is;  to  press  the 
injected  mass  well  into  the  parenchyma,  and  preferably  into  the  medullary 
substance,  where  the  vessels  are  more  numerous  and  larger.  The  previous 
flushing  of  the  kidney  with  water  moreover  much  facilitates  this  injection.  To 
distend  the  network  of  the  fatty  capsule,  Stahr  advises  us  to  use  subjects 
who  have  emphysema  of  the  perirenal  cellular  tissue. 

BIBLIOGRAPHY. — MASCAGNI,  loc.  cit.,  p.  44  et  tab.  XIV. — SAPPEY,  loc. 
cit.,  p.  123  et  pi.  XLVT,  Fig.  9. — TEICHMANX,  loc.  cit.,  p,  8. — RINDOWSKY. 
Die  Lymphgefasse  der  Niere.  Verh.  d.  3.  Vers.  ntss.  Naturf.  zu  Kiew,  1871.— 
DISSE.  Zur  Anatomie  der  Niere,  Sitzungsber.  der  Gesellsch.  zur  Beforderung 
der  gesammten  Naturwissensch.  zu  Marburg,  1898,  11°  8. — HERMANN  STAHR. 
Der  Lymphapparat  der  Niere,  Arch.  /.  Anat.  u.  Phys.,  Anat.  Abth.,  1900, 
p.  40. — CUNEO.  Note  sur  les  lymphatiques  du  rein,  Bull.  Soc.  anat.,  Paris, 
28  fevrier  1902. 


186  SPECIAL    STUDY    OF    THE    LYMPHATICS 

LYMPHATICS  OF  THE  SUPRARENAL  CAPSULES. — The  lymphatics  of 
the  suprarenal  capsules,  whose  mode  of  origin  will  be  studied 
together  with  the  structure  of  these  organs,  end  in  four  or  five 
collecting  trunks,  which  emerge  at  the  same  point  as  the  large 
central  vein.  These  trunks  terminate  in  the  juxta-aortic  glands  of 
the  corresponding  side.  In  several  subjects,  we  have  seen  some  of 
these  collecting  trunks  perforate  the  pillars  of  the  diaphragm,  and 
end  in  the  glands  placed  between  the  posterior  surface  of  these 
pillars  and  the  vertebral  column. 

5.  LYMPHATICS  OF  THE  SUB-DIAPHRAGMATIC  PORTION 
OF  THE  DIGESTIVE  TUBE. 

The  lymphatics  of  the  sub-diaphragmatic  portion  of  the  digestive 
tube  are  considerably  developed,  in  proportion  to  the  important 
part  they  have  to  play  in  the  absorption  of  food  which  has  already  been 
altered  by  the  digestive  juices.  We  will  not  here  consider  the  histo- 
logical  origin  of  these  vessels  within  the  intestinal  coats  ;  this  will 
be  described  together  with  the  structure  of  the  different  segments  of 
the  sub-diaphragmatic  portion  of  the  intestinal  tube.  We  will  now 
study  more  especially  the  macroscopic  arrangement  of  the  networks 
of  origin,  and  the  course  and  termination  of  the  collecting  trunks. 

LYMPHATICS  OF  THE  ANUS  AND  RECTUM. — (1)  NETWORKS  OF  ORIGIN. 
— The  lymphatic  vessels  of  the  anus  and  rectum  arise  from  two 
networks  ;  one  is  attached  to  the  muco-cutaneous  lining  of  the 
ano-rectal  region  ;  the  other  belongs  to  the  muscular  coat. 

(A)  The  muco-cutaneous  network  may  be  divided  into  three 
regions  :  inferior,  middle  and  superior. 

(a)  The  inferior  region  corresponds  to  the  skin  at  the  margin 
of  the  anus.     Here,  there  are  two    superposed    networks,  one  is 
superficial  or  cutaneous,  and  is  enclosed  within  the  actual  thickness 
of  the  skin,  while  the  other  is  deep  or  subcutaneous.     The  injection 
of  these  networks  is  easy,  and  it  generally  suffices  to  make  two  or 
three  punctures  to  fill  them  entirely.     Their  meshes  are  extremely 
close,  and  when  the  injection  is  made  with  mercury,  the  cutaneous 
network  appears  as  a  continuous  layer,  so  that  a  lens  is  necessary 
to  show  the  details  (vide  Fig.  67). 

(b)  The  middle  region  corresponds  to  the  skin  bordered  area  of 
the  anus  ;   its  upper  limit  is  therefore  formed  by  the  ano-cutaneous 
line  (white  line).     The  meshes  of  this  network,  which  are  much 
coarser  than  those  of  the  preceding  region,  have  a  vertical  direction. 

(c)  The  upper  region  corresponds  to  the  anal  mucous  membrane 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      187 


properly  so  called,  and  to  the  rectal  mucous  membrane.  In  the 
former,  the  lymphatic  network  is  little  developed.  In  the  latter, 
on  the  contrary,  it  is  extremely  rich,  but  the  fragility  of  its  meshes 


Superior  region 


Superior  hcemor- 
rhoidal  artery 


Superior  hcemor- 
rhoidal  gland 


Paracentral  gland 


Muscular  coat 


Mucous  coat 


Middle  region 
Inferior  region 


FIG.  67. — Lymphatics  of  the  rectum  (after  Gerota). 

The  posterior  wall  of  the  rectum  is  cut  to  show  the  mucous  membrane  ;  through  a  large 
window  made  in  the  upper  part  through  the  fibrous  coat,  the  blood  vessels  may  be  seen. 

render  its  injection  difficult.  As  is  the  case  in  the  rest  of  the  large 
intestine,  there  are  two  superposed  networks,  one  mucous  and 
the  other  sub-mucous. 


188 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


(B)  The  network  of  the  muscular  coat  is  very  difficult  to  inject. 
The  trunks  coming  from  this  network  unite  with  the  collecting 
trunks  from  the  nmco-cutaneous  networks. 

(2)  COLLECTING  TRUNKS. — Each  of  the  muco-cutaneous  linings 
possesses  distinct  efferents. 

(A)  The  inferior  region  gives  rise  to  from  three  to  five  trunks  on 
each  side.  These  run  towards  the  inguinal  region,  some  coursing 
on  the  internal  aspect  of  the  thigh,  others  over  the  perineum,  or  at 
the  level  of  the  perineo-crural.  f old. 


haemorrhoidal  channel  (Cuneo  and 

a.  Gland  of  the  external  chain  of  the  external  iliac  glands.  6.  Gland  of  the  middle  chain 
of  the  external  iliac  glands,  c.  Transverse  lymphatic  pedicle  of  the  prostate,  d.  Retro- 
prostatic  glands,  e.  Posterior  lymphatic  pedicle  of  the  prostate.  /.  Glands  of  the  pro- 
montory, g.  Lateral  sacral  glands,  h.  Middle  haemorrhoidal  gland,  t.  Rectal  afferent 
of  this  gland. 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      189 

Their  course  is  very  irregular.  They  describe  numerous  bends, 
and  often  bifurcate  en  route.  They  end  in  the  superficial  inguinal 
glands  ;  but  their  mode  of  termination  obeys  no  absolutely  fixed 
rules.  They  are  usually  tributaries  of  the  supero-internal  group  ; 
but  they  may  frequently  be  seen  to  terminate  in  the  infero-internal 
group,  or  to  empty  themselves  into  both  these  two  groups  at  the 
same  time.  It  is  much  more  rare  to  see  them  terminate  in  a  gland 
belonging  to  one  of  the  external  groups. 

In.  twenty-eight  cases,  Gerota  has  seen  the  cutaneous  lymphatics 
of  the  anus  end,  fifteen  times  in  the  supero-internal  group,  eight 
times  in  the  infero-internal  group,  four  times  in  these  two  groups 
at  the  same  time,  and  once  in  the  supero-internal,  infero-internal 
and  infero-external  groups. 

(B)  The  middle  region  possesses  numerous  efferents  which  we 
may  divide  into  indirect  and  direct.  The  former  ascend  in  the 
columns  of  Morgagni.  and  terminate  in  the  network  of  the  rectal 
mucous  membrane  (vide  Fig.  87).  The  direct  efferents  perforate  the 
rectal  Avail  and  gain  the  neighbouring  glands.  Taking  their  course 
and  termination  as  the  basis  for  our  classification  we  may  divide 
them  into  three  groups  :  (a)  Some  of  them  perforate  the  rectal 
wail  slightly  above  the  levator  ani,  then  ascend  on  the  lateral  walls 
of  the  rectum,  traverse  the  para-rectal  glands  which  will  be  described 
further  on,  join  the  collectors  coming  from  the  superior  region  and 
terminate,  as  the  latter  do,  in  the  glands  of  the  meso-rectum. 
(6)  Others,  coming  from  the  muscular  walls  of  the  rectum  at  the 
same  level  as  the  preceding,  are  satellites  of  the  middle  haemorrhoidal 
vessels  :  they  constitute  the  middle  haemorrhoidal  channel.  They 
usually  terminate  in  a  gland  placed  in  the  course  of  the  middle 
haemorrhoidal  artery  at  some  distance  from  the  lateral  wall  of  the 
pelvis,  (c)  The  collecting  trunks  of  the  third  group  (inferior 
haemorrhoidal  channel),  emerge  beneath  the  insertion  of  the  levator 
ani,  and  may  be  regarded  as  corresponding  to  the  system  of  the 
inferior  haemorrhoidal  vessels.  As  a  matter  of  fact,  however,  it 
is  rarely  that  they  follow  these  vessels  closely.  Most  frequently 
they  have  a  much  more  simple  course  ;  for,  after  running  a  very 
short  distance  in  the  adipose  tissue  of  the  ischio-rectal  fossa,  they 
perforate  the  levator  ani  and  terminate  in  a  gland  situated  at  the 
commencement  of  the  internal  pudic  artery,  within  the  pelvis. 

The  satellite  trunks  of  the  middle  haemorrhoidal  vessels  are  somewhat 
difficult  to  inject,  especially  when  mercury  is  used.  The  old  authors  made  no 
mention  of  them.  Quenu  and  Gerota  observed  them,  but  were  only  able  to 


190  SPECIAL    STUDY    OF    THE    LYMPHATICS 

inject  them  in  a  small  number  of  cases.  Marcille,  on  the  contrary,  employ- 
ing Gerota's  method  was  able  to  demonstrate  these  vessels  in  nearly  every  case. 
We  therefore  regard  this  middle  haemorrhoidal  channel  as  constant  ;  but  it 
does  not  always  present  the  very  simple  arrangement  which  we  have  just  in- 
dicated ;  in  fact,  one  of  the  satellites  of  the  middle  haemorrhoidal  artery  may 
be  seen  to  end  in  the  middle  gland  of  the  internal  chain  of  the  external  iliac 
group,  or  in  the  lateral  sacral  glands  :  Now  it  is  important  to  notice  that  the 
glands  into  which  these  aberrant  vessels  empty  themselves,  are  precisely  those 
in  which  the  normal  efferents  of  the  middle  haemorrhoidal  gland  end  (vide 
Fig.  68).  We  may  therefore  regard  these  lymphatic  trunks  as  afferents  of  the 
middle  haemorrhoidal  gland  which,  having  passed  by  their  first  glandular 
relay  have  directly  reached  their  second. 

The  trunks  which  correspond  to  the  system  of  the  inferior  haemorrhoidal 
vessels  are  passed  over  in  silence  by  the  majority  of  authors.  Marcille  and 
one  of  the  present  authors  have  injected  them  several  times ;  but  the  number 
of  our  observations  has  been  insufficient  to  enable  us  to  affirm  the  constancy 
of  this  inferior  haemorrhoidal  route. 

(C)  The  collecting  trunks  of  the  superior  region  pass  through 
the  muscular  coat  of  the  rectum  at  different  levels.  They  are 
most  frequently  satellites  of  the  vessels,  and  there  are  usually  two 
for  each  artery.  After  perforating  the  muscular  coat  of  the  rectum, 
they  run  obliquely  upwards  and  backwards,  and  reach  the  glands 
contained  in  the  meso-rectum.  In  their  perirectal  course,  they 
traverse  some  small  glands  which  have  been  well  described  by 
Gerota  and  which  we  will  call  para-rectal  glands  (ano-rectal  glands 
of  Gerota).  These  glands  vary  in  number  from  four  to  seven,  and 
are  placed  on  the  muscular  layer,  and  covered  by  the  fibro- 
serous  coat  of  the  rectum.  They  are  met  with  especiallv  in 
the  region  of  the  ampulla.  The  lowest  of  them  is  situated  imme- 
diately above  the  levator  ani.  The  superior  glands  on  the  contrary, 
may  be  found  projecting  underneath  the  serous  layer.  We  regard 
these  glands  as  simple  interrupting  glandular  nodules  placed  in  the 
course  of  the  juxta-rectal  collecting  trunks.  Apart  from  pathological 
cases  they  are  always  very  minute.  As  regards  the  glands  placed 
in  the  meso-rectum,  or,  if  we  prefer  to  call  it  so,  the  terminal  portion 
of  the  pelvic  meso-colon,  they  are  grouped  round  the  trunk  of  the 
superior  haemorrhoidal  artery.  They  are  always  of  considerable 
size  :  they  are  the  true  regional  glands  of  the  vessels  which  spring 
from  the  superior  lymphatic  region  of  the  rectum. 

The  arrangement  of  the  ano-rectal  collecting  trunks  may  be  thus 
summarized :  These  vessels  may  be  divided  into  three  groups  : 
an  inferior  group,  which  comes  from  the  skin  of  the  margin  of  the 
anus,  and  is  a  tributary  of  the  superficial  inguinal  glands  ;  a  middle 
group,  which  comes  from  the  region  of  the  white  line  and  ends  in 


LYMPHATICS    OF   THE   PELVIS    AND   ABDOMEN    191 

the  hypogastric  glands  ;  a  superior  group,  which  springs  from  the 
mucous  membrane  of  the  anus  and  rectum,  and  terminates  in  the 
glands  of  the  meso-rectum,  after  traversing  the  para-rectal  glandular 
nodules.  The  superior  group  corresponds  to  the  superior  haemor- 
rhoidal  vessels.  The  middle  group  corresponds  to  the  middle  and 
inferior  haemorrhoidal  vessels.  The  inferior  group  has  no  homo- 
logue  in  the  arterial  system. 

LYMPHATICS  OF  THE  ILIO-PELVIC  COLON. — The  lymphatics  of  the 
ilio-pelvic  colon  at  first  traverse  some  small  glands  which  are 
attached  to  the  terminal  branches  given  off  by  the  para-intestinal 
arch  and  formed  by  the  anastomosis  of  the  three  sigmoid  arteries. 
They  then  terminate  in  glands  placed  over  the  inferior  mesenteric 
artery. 

LYMPHATICS  OF  THE  DESCENDING  COLON. — The  lymphatic  vessels 
of  the  descending  colon  present  a  somewhat  similar  arrangement 
to  that  of  the  ilio-pelvic  colon.  We  need  only  note  the  poorly 
developed  glandular  apparatus  attached  to  this  part  of  the  large 
intestine. 

LYMPHATICS  OF  THE  TRANSVERSE  COLON. — The  lymphatic 
apparatus  of  the  transverse  colon  is  much  more  developed.  The 
juxta-intestinal  glands  (vide  p.  142)  are  here  numerous,  especially 
in  the  neighbourhood  of  the  two  extremities  of  the  transverse 
colon.  Further,  one  almost  constantly  finds  one  or  two  large 
glands  situated  in  the  angle  of  the  bifurcation  of  the  middle  colic, 
as  well  as  two  or  three  others  placed  along  the  trunk  of  this  artery. 
The  trunks  coming  from  the  latter  pass  into  the  glands  of  the  superior 
mesenteric  chain. 

The  lymphatics  of  the  transverse  colon  communicate  to  a  large  ex- 
tent with  those  of  the  great  omentum,  so  that  they  are  brought  into 
relation  with  the  lymphatics  of  the  inferior  border  of  the  stomach. 

LYMPHATICS  OF  THE  ASCENDING  COLON. — The  collecting  trunks 
emanating  from  the  ascending  colon  at  first  traverse  some  few 
juxta-intestinal  glands  :  they  then  meet  a  gland,  which  is  however 
inconstant,  placed  on  the  course  of  the  ascending  colic  artery,  and 
finally  terminate  in  the  glands  of  the  superior  mesenteric  chain. 

LYMPHATICS  OF  THE  COECUM  AND  APPENDIX. — The  lymphatics  of 
the  coecum  and  appendix  are  much  more  developed  than  those  of 
the  other  segments  of  the  large  intestine.  This  is  especially  true 
in  the  case  of  the  appendix,  the  lymphoid  tissue  of  which  is  known 
to  be  abundant.  The  mode  of  origin  of  these  vessels,  and  the 
arrangement  of  the  appendicular  lymphoid  apparatus  will  be  studied 


192 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


further  on  (vide  vol.  iv.  p.  334,  Fig.  178 1).  We  will  therefore  confine 
ourselves  here  to  indicating  the  arrangement  of  the  collecting 
trunks  of  the  coecum  and  the  appendix,  and  the  topography  of  their 
terminal  glands. 

The  coeco-appendicular  collecting  trunks  follow  pretty  closely 
the  course  of  the  blood  vessels.  This  fact  will  enable  us  to  divide 
them  into  three  groups  :  the  anterior  coecal,  the  posterior  coecal 
and  the  appendicular  trunks,  which  respectively  accompany  the 

vessels  of  this  name. 

(a)  The     anterior 
co  zeal     collecting 
trunks  appear  on  the 
anterior     surface    of 
the    coecum.       They 
run  upwards  and  in- 
wards, traversing  one 
or  twro  small  glands 
situated  in  the  thick- 
ness of   the   anterior 
ileo-coecai   fold,  and 
then  terminate  in  a 
glandular       mass 
placed    on    the    ter- 
minal segment  of  the 
ileo-coecal  artery 
(vide  Fig.  69). 

(b)  The    posterior 

FIG.  GO.-Lymphatics  of  the  coecum  and  appendix  (anterior  COeCCtl  Collecting  trunks 

view),  follow  the   course  of 

a.     Ileo-coecal     glands.        b.     Anterior     coecal     lymphatics.  ,  i  f       fi_  • 

c.    Anterior  coecal    glands,     d.  Gland    of    the   appendix   (sub-  tlie       artery 
ileal  group),     e.  Appendicular  afferents  of  this  gland.  name.      Like  the  pre- 

ceding, they  traverse  some  small  glands — the  posterior  coecal. 
The  latter,  from  three  to  six  in  number,  are  situated  on  the 
posterior  aspect  of  the  coecum,  at  the  junction  of  this  surface 
with  the  internal  surface.  Except  in  those  rare  cases  where  the 
coalescence  of  the  posterior  surface  of  the  coecum  and  the  parietal 
peritoneum  is  complete,  these  glands  are  covered  by  the  visceral 
layer  of  peritoneum  which  binds  them  to  the  posterior  surface 
of  the  coecum.  The  posterior  coecal  lymphatics  terminate  in 
the  ileo-coecal  glandular  group  (vide  Fig.  70). 

1  Treatise  of  Human  Anatomy.     Poirier  and  Charpy; 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN      193 

(c)  The  collecting  trunks  of  the  appendix,  four  or  five  in  number, 
run  up  between  the  layers  of  the  meso-appendix,  accompanying 
the  appendicular  artery.  Like  this  artery,  they  cross  the  posterior 
surface  of  the  terminal  segment  of  the  ileum,  then  penetrate  into 
the  mesentery,  and  terminate  in  the  ileo-coecal  glandular  group 
(vide  Fig.  70).  In  their  course,  these  lymphatics  traverse  some 
small  glands  which  we  class  under  the  generic  term  of  appendicular 
glands.  In  the  large  majority  of  cases,  these  glands  from  one  to 
three  in  number,  are  placed  in  the  retro-ileal  segment  of  the  meso- 


; Vr  Ifeo-ca'cal  artery 


~r —   Potterior  crccnl  artery 


Fig.  TO.—  Lymphatics  of  the  coccum  and  appendix  (posterior  view), 
a.  Ileo-coecal  glands,     fc.  Appendicular  glands  (retro-ileal  group),     c.  Retro-coecal  glands. 

appendix  ;  they  may  then  be  styled  the  retro-ileal  appendicular 
glands.  More  rarely  we  find  one  or  several  glands  in  the  sub-ileal 
portion  of  the  meso-appendix  ;  these  are  the  sub-ileal  appendicular 
glands.  Finally,  some  of  the  glands  of  the  meso-appendix  may  be 
placed  immediately  against  the  coecum,  above  the  origin  of  the 
appendix  ;  these  are  the  juxta-coecal  appendicular  glands. 

Tixier  and  Viannay,  who  have  recently  undertaken  the  study  of  the  topo- 
graphy of  the  appendicular  glands,  have  well  described  the  arrangement  of 
these  three  groups  which  we  have  styled  the  ileo-appendicular,  appendicular 
and  coeco-appenclicular.  The  ileo-appendicular  group  (appendicular,  retro- 
ileal  group)  is  the  most  constant.  It  was  present  in  36  out  of  100  cases. 
In  22  of  these  100  cases,  it  was  formed  by  only  a  single  gland  ;  in  10  of  these 
100  cases,  2  glands  were  present ;  in  4  of  these  100  cases,  there  were  more 
than  2  glands.  The  appendicular  group  (appendicular,  sub-ileal  group)  was 
found  in  12  out  of  100  cases.  In  14  of  these,  Tixier  and  Viannay  proved  the 


194  SPECIAL    STUDY    OF    THE    LYMPHATICS 

presence  of  the  coeco-appendicular  group  (appendicular  juxta-coecal  group). 
Finally  in  6  per  cent,  there  was  no  trace  of  glands  in  any  part  of  the  meso- 
appendix.  This  possible  absence  of  appendicular  glands  well  shows  that 
these  glands,  like  the  prae-  and  retro-coecal  glands,  are  simple  interrupting 
glandular  nodules  (Schaltdruse)  interposed  in  the  course  of  the  coeco- 
appendicular  lymphatics.  The  true  regional  glands  of  these  vessels  are  the 
glands  placed  in  the  mesentery  round  the  ileo-coecal  artery. 

The  appendicular  lymphatics  are  therefore,  eventually,  tributaries  of  the 
glands  which  form  the  terminal  segment  of  the  superior  mesenteric  chain. 

Some  authors  are  of  opinion  that  the  appendicular  tymphatics  have  a  much 
more  complicated  mode  of  termination.  "  I  have  so  often  found,"  says  Lock- 
wood,  "  a  chain  of  inflamed  lymphatic  glands  along  the  internal  border  of  the 
colon,  behind  the  ascending  meso-colon,  that  I  have  arrived  at  the  conclusion 
that  this  is  the  chief  route  followed  by  the  lymphatics  of  the  appendix. 
Other  lymphatics  without  doubt  pass  into  the  mesenteric  glands.  The 
lymphatics  of  the  appendix  also  empty  themselves  into  the  glands  of  the 
iliac  fossa,  lying  one  behind  the  other  along  the  length  of  the  external  iliac 
artery.  Some  also  run  along  the  appendiculo-ovarian  ligament  which  pass 
into  the  right  broad  ligament,  and  into  the  glands  of  the  right  lateral  wall  of 
the  pelvis,  close  to  the  internal  iliac  artery/'  This  classification,  which  is 
accepted  by  Tixier  and  Viannay,  appears  to  us  absolutely  visionary.  The  only 
normal  terminations  of  the  coeco-appenclicular  lymphatics  are  the  glands  of 
the  ileo-coecal  group.  However,  the  subserous  network  of  the  coecum  anas- 
tomoses with  that  of  the  adjacent  parietal  peritoneum,  and  it  is  through  this 
network  that  the  coeco-appendicular  lymphatics  may  communicate  with  some 
of  the  neighbouring  glandular  groups. 

Clado  has  described  an  anastomosis  between  the  lymphatics  of  the  appendix 
and  those  of  the  right  ovary  ;  this  anastomosis  runs  in  the  appendiculo-ovarian 
ligament.  Tixier  and  Viannay  have  found  a  small  lymphatic  gland  in  this  fold. 
We  have  never  proved  the  existence  of  the  anastomosis  described  by  Clado, 
and  we  formally  deny  its  presence. 

BIBLIOGRAPHY. — TUFFIER.  Btude  sur  le  coecum  et  ses  hernies.  Archives 
yenerales  de  medecine,  1887,  p.  641. — CLADO.  Appendice  ca?cal.  Mem.  de  la 
Soc.  de  biol.,  1892. — LAFFORGUE.  Recherchcs  anatomiques  sur  1'appendice 
vermiculaire  du  caecum.  Journ.  de  VAnat.  et  de  la  PhysioL,  1893. — LOCK- 
WOOD.  Note  upon  the  lymphatics  of  the  vermiform  appendix,  Journ.  of 
Anat.  and  Physiol.,  1900,  t.  XXXIV,  p.  xni.— TIXIER  et  VIANNAY.  Xote  sur 
les  lymphatiques  de  1'appendice  ileocaccal.  Lyon  medical,  1901. — AUGUY. 
De  I'adenopathie  appendiculaire.  These  Lyon,  1901. — BONJOUR.  Des 
adenopathies  peri-appendiculaires.  These  Paris,  1901. — QUENU.  Communic. 
Soc.  Chirurgie,  1  mai  1902. 

LYMPHATICS  OF  THE  SMALL  INTESTINE. — Like  the  lymphatics 
of  the  large  intestine,  the  lymphatics  of  the  small  intestine  form 
two  systems  relatively  independent  of  each  other,  one  of  which  is 
attached  to  the  mucous  layer,  and  the  other  to  the  muscular  coat. 
Details  of  the  origin  of  these  vessels  and  their  relations  with  the 
rich  lymphoid  tissue  which  is  connected  to  them  will  be  studied 
further  on  (vide  vol.  iv.  p.  300 1).  The  mode  of  termination  of  the 
collecting  trunks  of  the  small  intestine  is  not  the  same  in  the  region 
of  the  jejuno-ileum  as  in  that  of  the  duodenum. 

1  Treatise  of  Human  Anatomy.     Poiricr  and  Charpy, 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN     195 


LYMPHATICS  OF  THE  JEJUNO-ILEUM. — The  collecting  trunks, 
which  are  extremely  numerous,  make  their  appearance  in  the 
neighbourhood  of  the  mesenteric  border  of  the  intestine.  If 
examined  in  the  living  subject,  during  intestinal  digestion  they 
appear  as  slightly  bossed  channels  of  varying  calibre,  especially 
noticeable  on  account  of  their  milky  appearance.  They  terminate 
in  the  glands  contained  in  the  mesentery.  Though  these  glands 
appear,  at  first  sight,  to  be  indiscriminately  scattered  between  the 
two  folds  of  the  mesentery,  if  observed  more  attentively,  we  may 
convince  ourselves  that  they  are  arranged  on  some  fairly  definite 
plan.  It  is  also  possible  to  divide  them  into  three  groups  which 
vary  in  importance  and  signification. 

(a)  A  primary  group  comprises  some  small  glands  placed  on  the 
course  of  the  terminal 
arterioles  springing 
from  the  last  an- 
astomotic  arch,  or 
actually  over  the 
arch  itself.  Some- 
times, especially  at 
the  commencement 
of  the  jejunum,  these 
glands  are  immedi- 
ately contiguous  to 
the  intestine  and 
may  even  lie  on  the 
intestine  itself.  As 
we  have  seen,  they 
are  simple  interrupt- 
ing glandular  nodules 
(Schaltdriise)  which 
have  no  morphological  fixity. 

(6)  A  second  group  comprises  some  glands  placed  in  the  course 
of  the  primary  branches  of  the  superior  mesenteric  artery  and  at 
the  level  of  the  first  anastomotic  arch  formed  by  these  vessels. 
These  glands,  which  are  much  larger  than  the  preceding,  are  the 
true  regional  glands  of  the  jejuno-ileum. 

(c)  Finally,  a  third  group  of  glands  is  found  round  the  trunk  of 
the  superior  mesenteric  artery  and  more  particularly  round  the 
commencement  of  this  vessel.  This  group  does  not  properly 
belong  to  the  jejuno-ileum,  nevertheless  it  receives  the  efferents  of 


Fig.  71.—  Lymphatics  of  the  small  intestines  (after  Sappey) 

1.  Loop  of    small    intestine.     2,  3,  5,  7.  Lymphatic    col- 

lectors.    4.  Juxta-intestinal  gland.     6.  Mesenteric  vein. 

Mesenteric  artery. 


8. 


196 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


the  regional  glands  of  the  coecum,  the  ascending  and  transverse 
colon,  the  duodenum  and  even  the  afferents  of  certain  glands 
connected  with  the  stomach  (vide  p.  146). 

The  glands  are  especially  numerous  in  that  portion  of  the  mesen- 
tery which  corresponds  to  the  jejunum.  There  is  a  progressive 
diminution  in  the  number  of  glands  in  each  given  segment  of  the 
mesentery  until  the  terminal  segment  of  the  ileum  is  reached. 


Gland  of  the  hepatic  chain. 


Hepatic  artery. 


Splenic  vein. 


Superior  mesenteric  gland. 


Gland  of  common  bile  duct* 
Gland  of  common  bile  duct. 
Gastro-duodenil  artery. 

Retro-pincreatiz  gland. 
Portal  vein. 

Ketro-pincre'.itic  gland. 
Helro-pancrsatic  gland. 


Fig.   72. — Retro-pancreatic  glands. 

We  must,  however,  always  remember  that  in  the  ileo-coecal  region 
the  glands  again  reappear  in  numbers  and  form  an  important  mass 
round  the  ileo-coecal  artery. 

The  mesenteric  glands  constitute  one  of  the  most  important 
glandular  centres  in  the  human  system.  They  vary  in  number 
from  130  to  150  (Quain),  and  their  size  varies  greatly  in  different 
subjects.  In  certain  pathological  conditions  they  may  form  very 
large  tumours  which  cause  serious  trouble  in  the  abdominal  cir- 
culation. In  certain  animals,  they  are  grouped  into  a  compact 


LYMPHATICS    OF  THE  PELVIS   AND    ABDOMEN    197 

mass  which  the  old  anatomists  described  under  the  name  of  pancreas 
of  Aselli. 

LYMPHATICS  OF  THE  DUODENUM. — The  lymphatics  of  the  duo- 
denum end  in  numerous  collecting  trunks  which  are  arranged  on 
the  same  plan  as  those  of  the  jejuno-ileum,  but  the  pancreas  divides 
these  vessels,  like  the  corresponding  blood  vessels,  into  two  groups  : 
an  anterior  group,  the  vessels  of  which  end  in  glands  placed  on  the 
prae-pancreatic  vascular  arch  ;  a  posterior  group,  the  lymphatics  of 
which  terminate  in  the  satellite  glands  of  the  retro-pancreatic  arch. 
From  these  glands,  namely  the  prae-  and  retro-pancreatic,  run  two 
systems  of  efferents.  Some,  ascending,  terminate  in  the  glands  of 
the  hepatic  chain.  Others,  descending,  are  grouped  round  the 
superior  mesenteric  artery,  at  the  spot  where  this  vessel  crosses 
the  third  part  of  the  duodenum. 

The  close  relations  which  exist  between  the  lymphatics  of  the 
duodenum  on  the  one  hand  and  those  of  the  common  bile-duct  and 
pancreas  on  the  other,  should  be  noticed.  We  shall  see  later  on 
that  anastomoses  are  also  present  between  the  lymphatics  of  the 
duodenum  and  those  of  the  pyloric  portion  of  the  stomach  (vide 
p.  201). 

LYMPHATICS  OF  THE  STOMACH. — The  origin  of  the  lymphatics  of 
the  stomach  will  be  studied  together  with  the  structure  of  that 
organ  (vide  vol.  iv.  p.  241).  Here  we  need  only  call  to  mind  the 
fact  that  the  lymphatics  of  the  stomach,  like  those  of  the  intestine, 
ought  to  be  divided  into  mucous  and  sero-muscular.  The  lymphatics 
which  arise  in  the  mucous  membrane  finally  end  in  a  submucous 
network  ;  from  this,  collecting  trunks  arise  which,  in  the  neigh- 
bourhood of  the  curvatures,  perforate  the  muscular  coat  and  finally 
terminate  in  the  sero-muscular  collecting  trunks.  The  latter 
spring  from  a  sub-peritoneal  network  in  which  all  the  lymphatics 
which  come  from  the  muscular  coat  and  serous  layer  end.  These 
musculo-serous  collecting  trunks  may  be  divided  into  three  groups  : 
some  of  which  are  directed  towards  the  small,  others  towards  the 
large  curvature  ;  while  a  third  group  runs  towards  the  great 
tuberosity. 

1 .  The  collecting  trunks  of  the  first  group  (superior  or  converging 
trunks  of  Sappey)  are  the  most  important  and  the  largest.  Ac- 
cording to  Sappey,  they  may  usually  be  reckoned  as  from  six  to 
eight.  In  different  subjects  they  run  either  singly  or  in  triplets. 
The  majority  of  these  trunks  converge  towards  the  glands  of  the 
small  curvature,  which  are,  as  we  have  already  seen  (p.  143), 

N 


198 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


situated  around  the  spot  where  the  coronary  artery  approaches  the 
small  curvature.  Their  direction  varies  according  to  their  origin ; 
thus,  the  collecting  trunks  which  spring  from  the  body  of  the 
stomach  are  quite  vertical,  those  which  arise  from  the  pyloric 
vestibule  point  obliquely  upwards  and  to  the  left ;  and  the  trunks 
issuing  from  the  pylorus  run  parallel  to  the  small  curvature.  On 


FIG.  73.— General    view  of  the  subperitoneal  network  of  the  stomach,   injected  by 
Gerota's  method  (Cuneo). 

1.  Left  pneumogastric.  2.  Praecardiac  glands.     3.  Right  pneumogastric.     4.  Coronary 

artery,     o.  Coronary  vein.  6.  Gland  of  the  small  curvature.     7.  Hepatic  artery.     8.  Right 

gastro-epiploic  artery.  9.  Sub-pyloric  gland.  10.  Right  gastro-epiploic  vein  ending  in 
the  middle  colic  vein. 

the  contrary,  the  lymphatics  which  come  from  the  cardia  or  the 
sub-cardiac  zone,  descend  obliquely  downwards  and  to  the  right 
towards  the  point  of  common  convergence.  In  a  general  way 
then,  all  these  trunks  have  a  direction  parallel  to  that  of  the 
coronary  vessels. 

However,  one  or  two  very  fine  vessels,  which  come  from  the  upper 


LYMPHATICS   OF  THE   PELVIS   AND   ABDOMEN    199 

part  of  the  pylorus,  run  from  left  to  right  towards  the  pyloric 
artery  and  join  the  efferent  trunks  of  the  retro-pyloric  glands. 

2.  The  collecting  trunks  of  the  second  group,  or  collecting  trunks 
of  the  large  curvature,  are  more  numerous  but  smaller  than  the 
preceding.     They  vary  in  number  from  twelve  to  eighteen.     They 
usually,  but  not  necessarily,  accompany  the  branches  sent  by  the 
gastro-epiploic  vessels  to  the  stomach.     All  these  collecting  trunks 
end  in  the  sub-pyloric  glands  (vide  p.  146). 

The  lymphatics  coming  from  the  pylorus  or  the  pyloric  vestibule 
soon  join  these  glands  by  a  vertical  or  slightly  oblique  course.  As 
regards  the  other  collecting  trunks  which  come  from  the  body  of 
the  stomach,  instead  of  running  directly  downwards  and  to  the 
left  with  an  obliquity  varying  with  their  situation,  they  descend 
vertically  as  far  as  the  vascular  arch  which  runs  along  the  great 
curvature ;  there  they  quickly  change  their  direction  and  run 
parallel  to  this  arch.  During  their  course,  they  blend  together, 
forming  two  or  three  trunks  which  anastomose  with  one  another 
and  finally  end  in  the  sub-pyloric  glands  (vide  Fig.  73). 

3.  The  third  group  includes  all  the  trunks  coming  from  the  great 
tuberosity.     They  vary  in  number  from  three  to  six.     They  run  in 
the  gastro-splenic  omentum,  but  do  not  accurately  follow  the  course 
of  the  vasa  brevia  and  the  left  gastro-epiploic  arteries.     They  then 
penetrate  the  splenico-pancreatic  omentum,  and  terminate  in  the 
glands  placed  in  this  omentum,  close  to  the  hilum  of  the  spleen. 

To  sum  up,  we  may  say  that,  in  a  general  way,  the  collecting 
trunks  of  the  small  curvature  converge  towards  the  point  at  which 
the  coronary  artery  approaches  the  stomach,  and  pass  into  the  glands 
of  the  coronary  chain.  The  collecting  trunks  of  the  large  curvature 
run  from  left  to  right  towards  the  sub-pyloric  glands.  Finally,  the 
trunks  which  spring  from  the  great  tuberosity  are  directed  from 
left  to  right  towards  the  hilum  of  the  spleen,  and  end  in  the  glands 
of  the  splenic  chain. 

We  have  already  described  these  glandular  groups  (vide  prae-aortic  glands, 
p.  141,  and  Figs.  46  and  47)  and  therefore  will  not  return  to  this  point, 
but  we  must  here  note  the  possible  presence  of  little  interrupting  glandular 
nodules  in  the  course  of  these  different  collecting  trunks.  In  certain  cases, 
these  nodules  may  be  placed  within  the  actual  thickness  of  the  walls  of  the 
stomach  at  avariable  distance  from  the  curvatures.  Letulle  (Soc.  Anat.,  Dec. 
29,  1897)  was  the  first  to  draw  attention  to  this  arrangement,  of  which  one  of 
the  present  authors  has  met  with  three  examples.  These  parietal  gastric 
glands  usually  occupy  the  subserous  layer  or  the  superficial  portion  of  the 
muscular  coat. 

Lymphatic  Territories. — As  we  have  seen,  in  the  stomach  there  are  three 


200  SPECIAL    STUDY    OF    THE    LYMPHATICS 


distinct  lymphatic  territories,  to  the  arrangement  of  which  one  of  .the  present 
authors  drew  attention  in  his  thesis.  These  territories  correspond  to  the 
three  groups  of  collecting  trunks  which  we  have  described. 

The  territory  of  the  collectors  of  the  small  curvature  is  divided  from  the 
others  by  a  line  which  commences  a  little  to  the  left  of  the  cardia,  and  runs 
on  both  surfaces  of  the  stomach  following  a  line  nearly  parallel  to  the  large 

curvature. 

But  this  line  which  indicates  the  parting  of  the  lymph,  if  one  may  so  speak  of 

it,  is  much  nearer  the  large  than  the  small  curvature.  We  may  reckon  ap- 
proximately that  it  leaves  below  it,  a  third  only  of  the  surface  of  the  organ. 
It  is  important,  however,  to  remark  that  in  the  pyloric  region,  this  line  tends 
to  become  raised  and  to  be  placed  at  an  equal  distance  from  the  large  and  the 
small  curvature. 

The  limit  of  the  territories  of  the  collectors  of  the  second  and  third  groups  is 

more  difficult  to  determine  accurately  ; 
it  is,  moreover,  of  no  great  practical 
interest.  It  usually  corresponds  to  the 
junction  of  the  horizontal  with  the 
•3  vertical  portion  of  the  large  curvature. 

This  classification  is  the  same  on  the 
two  surfaces  of  the  organ  and  applies  as 
well  to  the  lymphatics  of  the  mucous 
membrane  as  to  those  of  the  musculo- 
serous  coat.  From  this  description  it 
follows  that  the  largest  and  most  im- 
portant of  the  three  lymphatic  territories 
of  the  stomach  is  that  of  the  col- 
lectors of  the  small  curvature  ;  these 
collectors  taken  together  represent  the 

74— Lymphatic    territories  of   the  principal    lymphatic     channel,    whereas 

the  collecting  trunks  of  the  other  two 

1.  The  coronary  or  the  principal  current,  groups  are  onlv  accessory  channels. 
2.  Right  gastro-epiploic  current.  3.  Splenic  Anastomoses.— The  lymphatic  appara- 
tus of  the  stomach  contracts  im- 
portant relations  with  the  lymphatics  of  neighbouring  organs.  These  relations 
are  of  two  kinds :  some  are  effected  by  the  anastomoses  which  exist  between  the 
different  gastric  networks  with  the  two  adjacent  portions  of  the  digestive 
tube,  viz.  the  oesophagus  and  duodenum ;  others  are  the  result  of  the  presence  of 
glandular  groups  which  are  common  to  the  gastric  lymphatics  and  those  of 
neighbouring  organs,  viz.  the  liver,  pancreas,  and  spleen.  We  shall  here  only 
lay  stress  on  the  former. 

The  two  principal  networks  of  the  stomach,  viz.  the  submucous  and  the 
subserous  networks,  communicate  largely  with  the  two  homologous  networks 
of  the  abdominal  portion  of  the  oesophagus.  As  is  shown  in  Sappey's  fine 
plates,  there  is  even  a  true  continuity  between  the  gastric  and  oesophageal 
networks.  This  anatomical  arrangement  is  thoroughly  in  accord  with  known 
facts  of  pathological  anatomy,  which  teaches  us  that  neoplasms  of  the  cardia 
easily  infect  the  inferior  portion  of  the  oesophagus  and  inversely. 

Does  the  same  hold  good  in  the  case  of  the  duodenum  ?  This  question  must 
be  discussed  separately  for  the  subserous  and  for  the  submucous  network. 

Sappey's  plate  shows  an  absolute  continuity  between  the  subserous  net- 
work of  the  stomach  and  that  of  the  duodenum.  According  to  Most,  on  the 
contrary,  there  is  no  communication  between  these  two  networks,  and  in  the 


Fig. 


LYMPHATICS    OF  THE   PELVIS   AND   ABDOMEN       201 

pyloric  region  a  trunk  having  more  or  less  annular  direction  forms  a  very 
clear  limit  to  the  subperitoneal  gastric  network. 

Our  researches  have  led  us  to  the  same  conclusions  as  Mnst's,  that  is.  so  far 
as  the  absence  of  communication  between  the  subserous  network  of  the  stom- 
ach and  the  corresponding  part  of  the  duodenum  is  concerned,  but  we  have 
never  been  able  to  inject  the  annular  vessel  to  which  he  alludes.  In  one  case, 
we  saw  a  collecting  trunk  of  the  pylorus  break  through  the  gastro-duodenal 
limit,  and  run  a  few  millimetres  on  to  the  commencing  portion  of  the  duodenum, 
and  reach  a  gland  belonging  to  the  sub-pyloric  group,  which  was  much 
drawn  to  the  right  side. 

Nevertheless,  we  do  not  wish  to  raise  the  slightest  doubt  as  to  the  existence 
of  communications  between  thesubmucous  networks  of  the  stomach  and  duo- 
denum. One  of  the  present  writers  has  several  times  shown  the  existence  of 
these  communications,  and  Most  has  even  succeeded  in  filling  the  collecting 
trunks  of  the  initial  portion  of  the  duodenum  and  their  glands,  by  injecting  the 
mucous  membrane  of  the  pylorus.  We  must,  however,  recognize  the  fact, 
that  these  anastomoses  between  the  lymphatics  of  the  gastric  mucous  mem- 
brane and  those  of  the  duodenal  mucous  membrane  do  not  show  a  high  grade 
of  development ;  but  none  the  less  they  play  a  very  important  part  in  those 
cases  where  the  duodenum  is  invaded  by  cancer  of  the  pj'lorus. 

BIBLIOGRAPHY. — MASCAGNI,  loc.  cit.,  p.  49  et  tab.  XVIII.— SAPPEY,  loc. 
cit.,  p.  76  et  suiv.,pl.  XXV,  Fig.  1. — MOST.  Ueber  die  Lymphgefasse  und  die 
regionare  Lymphdriisen  des  Magens,  etc.  Arch.  /.  klin.  Chir.,  LIX,  1,  p.  175. — 
CUXEO.  De  1'envahissement  du  systeme  lymphatique  dans  le  cancer  de 
1'estomac  et  de  ses  consequences  chirurgicales.  These  Paris,  1900. — CUNEO  et 
DELAWARE.  Anatomie  et  Histologie  des  lymphatiques  de  1'estornac.  Journ. 
de  VAnat.  et  de  la  PhysioL,  1900. 

LYMPHATICS  or  THE  LIVER. — As  we  shall  see  further  on  (vide1  vol. 
iv.  p.  766),  we  have  not  yet  any  perfectly  definite  knowledge  as  to  th 
arrangement  of  the  lymphatic  channels  within  the  hepatic  lobules. 
On  the  other  hand,  it  is  easy  to  demonstrate  the  lymphatic  networks 
in  the  interlobular  connective  tissue.  From  this  network  numerous 
collecting  trunks  start,  and  these  may  be  divided  into  two  chief 
groups.  Some,  springing  from  the  peripheral  lobules,  run  towards 
the  surface  of  the  hepatic  gland  passing  underneath  the  peritoneum  : 
these  are  the  superficial  collectors.  Others,  coming  from  lobules 
more  deeply  situated,  accompany  the  branches  of  the  portal  vein 
or  the  hepatic  veins  and  emerge  at  the  point  of  entrance  or  exit  of 
these  vessels.  These  are  the  deep  collectors. 

1.  The  Superficial  Collecting  Trunks.— We  will  study  first  the 
collecting  trunks  on  the  superior  and  then  those  on  the  inferior 
surface. 

1.  THE  COLLECTING  TRUNKS  ON  THE  SUPERIOR  SURFACE.— These  may 
be  divided  into  three  groups  :  posterior,  anterior  and  superior. 

(a)  The  posterior  collecting  trunks  run  towards  the  posterior 
surface  of  the  liver.  They  may  be  divided  into  right,  middle  and 

1  Treatise  of  Human  Anatomy.     Poirier  and  Charpy. 


202  SPECIAL    STUDY    OF    THE    LYMPHATICS 

left.     The  right  trunk,  which  is  usually  single,  appears  near  the 


2  2 


D  5  6     7       989 


D    12  13 


-  E 


II 


Fig.  75. — lymphatics  on  the  superior  surface  of  the  liver  (Sappey). 

A,  A.  Right  lobe  of  liver.  B,  13.  The  left  lobe.  C,  C.  The  suspensory  ligament  which 
partly  hides  the  superior  surface  of  the  left  lobe.  D,  D.  A  triangular  segment  of  the  dia- 
phragm which  has  been  incised  at  the  level  of  the  attachment  of  the  suspensory  ligament. 
E.  Left  triangular  ligament  of  the  liver.  F.  Inferior  extremity  or  base  of  the  gall  bladder. 

1,1.  Large  lymphatic  trunk  situated  on  the  right  border  of  the  right  lobe  ;  this  trunk 
descends  on  to  the  concavity  of  the  diaphragm  and  passes  into  one  of  the  glands  which  lie  on 
the  head  of  the  pancreas.  2,  2,  2,  2,  2.  Smaller  and  shorter  trunks  which  turn  round  the 
upper  border  of  the  liver  ;  all  terminate  in  the  small  glands  situated  round  the  inferior  vena 
cava,  immediately  above  the  diaphragm.  3.  Another  trunk,  which  takes  an  opposite  direc- 
tion to  the  preceding,  and  which  turns  round  the  inferior  border  or  edge  of  the  gland,  and 
then  runs  on  to  the  opposite  surface  towards  the  glands  of  the  hilum.  4,  4,  4,  4.  Trunldets 
which  spring  from  a  small  group  of  convergent  branches  on  the  surface  of  the  liver,  and  which 
plunge  almost  at  once  into  the  hepatic  tissue  and  then  rim  in  the  channels  of  Glisson's  capsule. 
5,  5.  A  very  beautiful  network  which  corresponds  to  the  adherent  border  of  the  suspensory 
ligament.  6,  6.  Trunks  in  which  all  the  little  branches  of  this  network  end.  7.  A  group  of 
convergent  trunks  which  start  from  the  same  vessels  and  which  run  obliquely  between  the 
two  layers  of  the  suspensory  ligament.  8.  A  very  large  trunk  formed  by  the  fusion  of  the 
preceding  trunks  ;  it  also  passes  obliquely  through  the  diaphragm,  and  then  creeps  along 
the  anterior  portion  of  its  convex  surface.  9,  9.  Glands  in  which  its  branches  end.  10. 
Another  trunk  also  situated  in  the  suspensory  ligament  ;  it  arises  from  the  network  which 
corresponds  to  the  base  of  this  fold,  is  directed  downwards,  and  then  passes  into  the  longi- 
tudinal fissure  of  the  liver  and  ramifies  in  one  of  the  glands  of  the  hilum.  11,  11.  Network 
resting  on  the  left  lobe  of  the  liver  ;  this  is  only  seen  owing  to  the  transparency  of  the  liver 
substance.  12.  A  group  of  trunks  which  ascend  towards  the  superior  border  of  the  left 
lobe  where  they  bend,  and  then  run  towards  the  glands  situated  round  the  inferior  vena 
cava.  13.  Another  more  important  group  which  at  first  follows  the  same  course,  but,  after 
traversing  the  left  triangular  ligament,  is  inclined  downwards  and  inwards,  towards  the 
glands  of  the  terminal  part  of  the  oesophagus,  in  which  it  is  lost.  14,  14,  14.  Trunks  which 
disappear  almost  immediately,  penetrating  into  Glisson's  capsule. 

right  extremity  of  the  liver.     It  runs  downwards  and  backwards 
and  penetrates  into  the  right  triangular  ligament.     It  then  attaches 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN          203 
itself  to  the  concave  surface  of  the  diaphragm,  then  crosses  the 


/          11  12  13  13    6D  6  6       6  A*  1 


Fig.   76. — Lymphatics  of  the  inferior  surface  of  the  liver  (Sappey). 

A,  A.  Large  or  right  lobe  of  the  liver.  B,  B.  Small  or  left  lobe.  C.  Quadrate  lobe.  D. 
Spigelian  lobe.  E.  Cord  resulting  from  the  obliteration  of  the  umbilical  vein.  F.  Gall 
bladder.  H.  Left  triangular  ligament  of  the  liver.  /.  Corresponding  part  of  the  diaphragm. 
A'.  The  most  projecting  part  of  the  superior  or  convex  border  of  the  liver. 

1,  1.  Two  large  lymphatic  trunks  which  arise  in  the  neighbourhood  of  the  right  border 
of  the  liver,  and  run  along  the  superior  border,  terminating  in  one  of  the  glands  which  sur- 
round the  inferior  vena  cava  at  its  entrance  into  the  thorax.  2.  Large  lymphatic  trunk 
coming  from  the  central  portion  of  the  inferior  surface  of  the  right  lobe,  which  runs  towai'ds 
the  hilum  of  the  liver  and  passes  into  the  gland  corresponding  to  the  neck  of  the  gall  bladder. 
3,  3.  Other  important  trunks  which  also  arise  round  the  gall  bladder,  and  anastomose  on 
the  interior  surface  of  the  latter,  and  then  pass  to  the  glands  situated  on  the  inferior  border 
of  the  hilum  of  the  liver.  4.  Two  trunks  which  have  the  same  origin  as  the  preceding  ; 
but,  instead  of  running  on  the  free  surface  of  the  gall  gladder,  they  pass  in  front  of  its  attached 
surface,  and  end  in  the  same  glands  ;  their  course  is  indicated  by  dotted  lines,  and  they 
ar«  only  ^isible  when  the  gall  bladder  has  been  previously  detached.  5,  5.  Trunks  which  also 
arise  from  the  inferior  surface  of  the  right  lobe,  in  a  lymphatic  network,  but  which  dis- 
appear almost  at  once  and  follow  the  course  of  the  divisions  of  the  portal  vein,  and  are  directed 
towards  the  hilum.  6,  6,  0.  Small  trunks  which  come  from  the  Spigelian  lobe,  and  the  glands 
in  which  they  terminate.  7,  7.  Vessels  springing  from  the  quadrate  lobe.  8,  8.  Principal 
lymphatic  trunks  of  the  left  lobe.  9,  9.  Other  trunks  which  arise  from  the  surface  of  the 
same  lobe,  but  which,  immediately  after  their  origin,  plunge  into  the  liver  substance,  to 
run  with  the  vessels  of  Glisson's  capsule.  10.  Trunk  which  we  have  seen,  arises  from  the 
superior  surface  of  the  left  lobe  ;  it  accompanies  the  umbilical  cord  and  terminates  in  one 
of  the  glands  of  the  hilum.  11,  11.  Two  trunks,  visually  large,  which  also  arise  from  the 
superior  surface  of  the  left  lobe,  and  which  traverse  the  corresponding  triangular  ligament 
and  end  in  a  gland  situated  at  the  posterior  extremity  of  the  longitudinal  fissure  ;  from 
this  gland  run  vessels  which  end  in  the  glands  of  the  hilum.  12.  Other  trunks  which  also 
come  from  the  superior  surface  of  the  left  lobe  and  end  in  the  same  glands  as  the  preceding. 

13,  13.  Glands  in  which  the  vessels  coming  from  the  superior  surface  of  the  liver,  terminate. 

14.  Glands  which  correspond  to  the  terminal  portion  of  the  oesophagus.      15,  15,  15,  15. 
Glands  which  receive  all  the  satellite  vessels  of  the  portal  vein,  and  the  majority  of  those 
which  run  down  from  the  inferior  surface  of  the  liver. 

anterior  surface  of  the  right  pillar  of  the  diaphragm  to  terminate 


204  SPECIAL    STUDY    OF    THE    LYMPHATICS 

in  one  of  the  glands  placed  round  the  origin  of  the  coeliac  axis 
(vide  p.  141).  The  middle  trunks,  five  to  seven  in  number,  run 
towards  the  inferior  vena  cava,  in  company  with  which  they  traverse 
the  caval  opening  in  the  diaphragm  and  terminate  in  the  glands 
situated  in  the  thorax  round  the  terminal  segment  of  this  venous 
trunk  (middle  and  right  groups  of  the  diaphragmatic  glands)  (vide 
p.  209).  The  left  trunks,  which  spring  from  the  left  extremity  of 
the  superior  surface,  penetrate  into  the  thickness  of  the  left  triangular 
ligament,  and  are  directed  towards  the  oesophagus  and  terminate 
in  the  glands  placed  round  the  abdominal  segment  of  this  tube  ; 
these  glands  we  have  already  described  with  the  coronary  chain, 
with  which  they  are  continuous. 

(6)  The  anterior  collecting  trunks  follow  a  course  diametrically 
opposite  to  that  of  the  preceding.  They  are  much  less  important 
and  rarely  exist  except  in  the  right  lobe.  They  are  directed  towards 
the  anterior  border  of  the  liver,  round  which  they  turn,  course 
along  the  quadrate  lobe  and  terminate  in  the  superior  glands  of 
the  hepatic  chain  (glands  of  the  hilum). 

(c)  The  superior  or  ascending  collecting  trunks  arise  from  that 
portion  of  the  superior  surface  which  is  near  to  the  insertion  of  the 
suspensory  ligament.  They  are  the  most  important  of  the  three 
groups  of  the  collectors  of  the  superior  surface.  Within  the  sus- 
pensory ligament  they  exchange  numerous  anastomoses  and  ter- 
minate, according  to  Sappey,  in  the  following  manner  :  A  posterior 
trunk  turns  round  the  posterior  border  of  the  liver,  and  embraces 
the  inferior  vena  cava,  in  company  with  which  it  enters  the  thorax 
and  terminates  in  the  glands  placed  round  the  intra-thoracic  portion 
of  this  large  venous  trunk.  An  anterior  trunk  turns  round  the 
anterior  border  of  the  liver,  and  in  company  with  the  umbilical 
cord  on  the  inferior  surface  of  the  liver,  reaches  one  of  the  superior 
glands  of  the  hepatic  chain.  Many  middle  trunks  "  run  from  below 
upwards  in  the  suspensory  ligament ;  these,  which  may  be  eight  or 
ten  or  only  three  or  four  in  number,  unite  beneath  the  diaphragm, 
forming  a  very  short  enormous  trunk  which  traverses  the 
muscle,  it  then  divides  almost  immediately  into  two  or  three  branches 
which  terminate  in  a  small  group  of  very  small  glands  situated  in 
front  of  the  pericardium,  behind  the  base  of  the  xiphoid  cartilage  ; 
these  are  the  supra-xiphoid  glands  "  (Sappey). 

2.  COLLECTING  TRUNKS  OF  THE  INFERIOR  SURFACE. — We  will  study 
in  turn— the  collecting  trunks  of  the  right,  the  left,  the  Spigelian 
and  the  quadrate  lobes. 


LYMPHATICS  OF  THE  PELVIS  AND  ABDOMEN         205 

(a)  The  collecting  trunks  of  the  right  lobe  may  be  divided  into 
posterior,   middle  and  anterior.     The  posterior  collecting  trunks, 
usually  two  in  number,  run  to  the  junction  of  the  inferior  and  pos- 
terior surfaces  ;  they  are  directed  transversely  inwards,  and  embrace 
the  inferior  vena  cava,  and  terminate  in  the  glands  placed  round 
the  intra-thoracic  segment  of  this  vessel.     The  middle  collecting 
trunks,   which  spring  from  the  middle  portion  of  the  lobe,  run 
directly  inwards  towards  the  hilum  and  terminate  in  the  superior 
glands  of  the  satellite  chain  of  the  cystic  duct  and  more  particularly 
in  the  cystic  gland.     The  anterior  collecting  trunks,  smaller  but 
more  numerous,  run  backwards  and  inwards.     Some  pass  above, 
and  others  beneath  the  gall  bladder,  and  end  in  the  same  way  as 
the  former. 

(b)  The  collecting  trunks  of  the  left  lobe  all   terminate  in  the 
glands  of  the  hilum  and  more  particularly  in  the  glands  of  the 
satellite  chain  of  the  hepatic  artery.     The  middle  collectors  run 
transversely.     The  anterior  collectors  closely  accompany  the  cord 
of  the  umbilical  vein,  the  posterior  accompany  the  vein  and  join 
their  respective  terminal  glands. 

(c)  The  collecting  trunks  of   the  Spigelian  lobe  terminate,  some 
in  the  glands  of  the  hilum,  others  in  the  glands  placed  round  the 
thoracic  segment  of  the  inferior  vena  cava. 

(d)  The  collecting  trunks  of  the  quadrate  lobe,  which  are  very 
numerous,  but  very  fine,  terminate  in  the  glands  of  the  Mum. 

The  trunks  which  we  have  just  described  on  the  superior  and 
inferior  surfaces  of  the  liver  do  not  collect  all  the  lymphatics  which 
come  from  the  superficial  lobules.  Some  of  these  lobules  send  their 
vessels  into  the  deep  collecting  trunks.  These  superficial  regions, 
tributaries  of  the  deep  vessels,  appear  as  stellate  figures,  whose 
centre  corresponds  to  the  origin  of  the  trunk  which  plunges  into 
the  depth  of  the  organ.  These  figures  are  especially  numerous  in 
the  neighbourhood  of  the  two  extremities  of  the  liver  (4,  4,  Fig.  75). 

II.  Deep  Collecting  Trunks. — The  deep  collecting  trunks  form 
two  absolutely  distinct  groups.  Some,  the  descending,  are  satellites 
of  the  portal  vein.  Others,  the  ascending,  accompany  the  hepatic 
veins. 

1.  The  descending  collecting  trunks  run  in  the  thickness  of  the 
capsule  of  Glisson,  and  thus  accompany  the  branches  of  the  portal 
vein,  the  hepatic  artery  and  the  biliary  passages.  For  each  branch 
of  the  portal  vein  there  are  usually  three  or  four  lymphatic  trunks 
which  anastomose  with  each  other.  In  their  course,  they  unite 


206  SPECIAL    STUDY    OF    THE    LYMPHATICS 

one  with  another  and  become  progressively  reduced  in  number : 
though  their  mode  of  branching  does  not  approach  in  regularity 
that  of  the  corresponding  blood  vessels.  On  emerging  at  the  hilum, 
they  number  from  fifteen  to  eighteen  (Sappey).  They  are  often 
grouped  in  two  distinct  bundles  which  are  apparent  at  the  two 
extremities  of  the  transverse  fissure.  They  terminate  in  the  glands 
of  the  hilum. 

2.  The  ascending  collecting  trunks  which  were  discovered  by 
Sappey  in  1850,  form  round  the  branches  of  the  hepatic  veins  a 
plexiform  sheath  which  is  easy  to  inject.  "  The  larger  and  smaller 
trunks  which  contribute  to  the  formation  of  this  sheath  creep  along 
the  adherent  surface  of  the  venous  walls  and,  like  the  latter,  are 
directed  towards  the  inferior  vena  cava.  The  trunks  are  reduced 
to  five  or  six  in  number  on  reaching  the  opening  in  the  diaphragm, 
through  which  they  pass  to  empty  themselves  into  the  glands 
situated  immediately  above  "  (Sappey). 

To  sum  up,  the  lymphatics  of  the  liver  terminate  in  the  following 
glandular  groups:  (1)  The  glands  of  the  hilum.  (2)  The  intra- 
thoracic  glands  placed  round  the  terminal  segment  of  the  inferior 
vena  cava.  (3)  The  supra-xiphoid  glands.  (4)  The  peri-oesophageal 
glands,  which  are  continuous  with  the  gastric  coronary  chain  group. 
(5)  The  glands  placed  round  the  coeliac  axis. 

The  most  important  of  these  glandular  groups,  as  far  as  the 
regional  glands  of  the  liver  are  concerned,  are  the  glands  of  the  hilum 
and  the  glands  placed  round  the  terminal  segment  of  the  inferior 
vena  cava  ;  these  latter  will  be  studied  later  on  (vide  p.  209). 
As  regards  the  glands  of  the  hilum,  we  must  be  careful  to  remember 
that  it  is  very  rare  to  see  them  arranged  in  a  single  bundle,  placed 
transversely,  below  the  transverse  fissure.  The}*  usually  form  two 
vertical  chains  which  are  more  or  less  continuous,  one  of  which  is  a 
satellite  of  the  hepatic  artery,  and  the  other  of  the  cystic  and  common 
bile-duct  (vide  Fig.  48  and  p.  147). 

We  should  note  the  frequent  but  not  constant  presence  of  one  or  two  glands 
sometimes  of  large  size,  in  the  depression  for  the  inferior  vena  cava,  in  front 
of  this  vessel. 

BIBLIOGRAPHY. — Sur  les  origines,  voy.  :  T.  IV,  p.  766,  et  MALL.  Proceed- 
ings of  the  Assoc.  of  American  Anatomists,  1902.  H  < — <]  '  •"''-)  I 

Sur  1'anat.  macr.  :  MASCAGNI,  loc.  cit.,  tab.  XVII  et  XVIII, ~et~p.  45.— 
SAPPEY,  loc.  cit.,  pi.  XXXV  et  XXXVI,  et  p.  94. 

Lymphatics  of  the  extra-hepatic  biliary  passages. — The  lymphatics 
of  the  extra-hepatic  biliary  passages  arise  from  two  networks, 


LYMPHATICS   OF  THE  PELVIS  AND  ABDOMEN         207 

one  mucous,  and  the  other  muscular.  The  collecting  trunks  which 
arise  from  these  networks  end  in  the  glandular  satellite  chain  which 
is  a  satellite  of  the  cystic  and  common  bile-duct.  Intimate  rela- 
tions exist  between  the  lymphatics  of  the  terminal  segment  of  the 
common  bile-duct  and  the  lymphatics  of  the  duodenum  and  head 
of  the  pancreas. 

LYMPHATICS  OF  THE  PANCREAS. — The  lymphatics  of  the  pancreas 
arise  from  a  perilobular  capillary  network  which  will  be  described 
further  on  (vide  1  vol.  iv.  p.  830).  From  this  network  run  numerous 
collecting  trunks  which  after  anastomosing  on  the  surface  of  the 
gland,  terminate  in  the  peri-pancreatic  glandular  groups. 

(1)  The  greater  number  of  them  reach  the  glands  of  the  splenic 
chain  (vide  p.  144).  (2)  Others  end  in  glands  which  are  satellites 
of  arches  formed  by  the  anterior  and  posterior  pancreatico-duodenal 
arteries.  (3)  A  third  group  empties  itself  into  the  glands  placed 
round  the  commencement  of  the  superior  mesenteric  artery.  (4) 
Finally  others,  which  spring  from  the  posterior  surface  of  the  pan- 
creas, terminate,  according  to  Sappey ,  in  the  left  j  uxta-aortic  glands  ( ? ) 

Technique. — The  injection  of  the  lymphatics  of  the  pancreas  is  very  diffi- 
cult, and  it  is  essential  that  perfectly  fresh  subjects  should  be  used.  On  the 
other  hand,  when  the  injection  succeeds,  it  is  usually  quite  complete.  Sappey 
recommends  for  choice  the  pancreas  of  old  subjects. 

THE  LYMPHATICS  OF  THE  SPLEEN. — The  lymphatics  of  the  spleen, 
whose  mode  of  origin  will  be  studied  further  on  (vide L  vol.  iv.  p.  867), 
give  origin  to  two  kinds  of  collecting  trunks  which  are  distinguished 
as  superficial  and  deep. 

^^superficial  collecting  trunks,  which  were  observed  by  Mascagni, 
and  then  by  Robin  and  Legros,  are  very  difficult  to  inject  in  man. 
Sappey  even  denies  their  existence.  They  are,  on  the  contrary,  well 
developed  in  the  ox  and  horse.  In  these  animals  they  form  a  rich 
network,  which  is  situated  between  the  peritoneum  and  the  fibrous 
capsule  of  the  spleen.  They  then  run  towards  the  hilum  of  the 
spleen  and  terminate  in  the  same  way  as  the  deep  collecting  trunks. 

The  deep  collecting  trunks,  which  are  connected  to  the  preceding 
by  numerous  anastomoses,  are  satellites  of  the  blood  vessels.  In  the 
hilum  they  are  reduced  to  from  six  to  ten  trunks  which  end  in  the 
external  glands  of  the  splenic  chain  ;  these  glands  are  placed  above 
the  tail  of  the  pancreas  in  the  splenico-pancreatic  omen  turn.  There 
are  usually  no  glands  in  the  gastro-splenic  omentum  ;  the  glands 
which  have  been  observed  here  by  some  authors  are  probably  nothing 
but  accessory  spleens,  winch  are  very  common  in  this  situation. 

1  Treatise  of  Human  Anatomy.     Poirior  and  Charpy. 


CHAPTER  III 
LYMPHATICS  OF  THE  THORAX 

WE  will  study  in  succession  :  (1)  the  different  glandular  groups  of 
the  thorax,  (2)  the  arrangement  of  the  lymphatic  vessels  of  the 
walls  of  the  thorax,  and  of  the  intra-thoracic  viscera. 

§  1.  GLANDULAR  GROUPS  OF  THE  THORAX. 
The  glandular  groups  of  the  thorax  may  be  divided  into  parietal 
and  visceral  glands. 

1.  PARIETAL  GLANDS 

The  parietal  glands  comprise  :  the  diaphragmatic  glands,  the 
internal  mammary  or  retro-sternal  glands  and  the  intercostal 
glands. 

Some  of  the  glands  of  the  axilla  belong  to  the  lymphatic  apparatus  of  the 
thoracic  walls,  but  as  it  is  impossible  to  subdivide  our  study  of  the  axillary 
glands,  we  will  leave  aside  for  the  present  this  thoracic  group  of  axillary 
glands. 

DIAPHRAGMATIC  GLANDS. — Under  the  name  of  diaphragmatic 
glands,  we  will  describe  all  the  glands  which  lie  on  the  convexity 
of  the  diaphragm.  They  may  be  divided  into  three  groups  :  an 
anterior,  a  middle  and  a  posterior  group. 

(a)  The  ANTERIOR  GROUP  rests  upon  the  anterior  fasciculi  of 
the  fleshy  portion  of  the  diaphragm,  in  front  of  the  anterior  leaflet 
ofjthe  central  portion  of  the  diaphragm.  It  is  formed  by  three 
distinct  masses  :  viz.  a  median  and  two  lateral,  symmetrically 
arranged. 

The  median  mass  comprises  two  or  three  glands,  placed  immedi- 
ately behind  the  base  of  the  xiphoid  cartilage.  These  are  the 
supra-xiphoid  glands  of  Sappey.  These  glands  receive  their  afferents 
from  the  superior  surface  of  the  liver  (vide  p.  203  and  Fig.  75)  : 
on  the  other  hand,  they  receive  no  vessels  coming  from  the  diaphragm 
(Sappey).  Their  efferents  pass  into  the  inferior  glands  of  the 
internal  mammary  chain. 

The  lateral  masses  are  formed  by  two  glands,  often  by  a 
single  one.  This  gland  is  placed  opposite  the  anterior  extremity  of 


208 


L    ~~ 


FIG.  77. — Lymphatics  of  the  superior  surface  of  the  diaphragm  (Sappey). 

A.  Xiphoid  cartilage.  B,  B.  Fifth  rib.  C,  C.  Sixth  rib.  D,  D.  Seventh 
rib.  E.  Eighth  rib.  F.  Ninth  rib.  G.  Tenth  rib.  H.  Eleventh  rib.  K.  Twelfth  rib. 
L.  L.  L,  L.  Right  and  left  halves  of  the  muscular  portion  of  the  diaphragm.  M,  M.  Pillars 
of  the  diaphragm.  N.  Central  aponeurotic  portion  of  the  diaphragm  with  i;s  three  leaflets. 
0.  Oesophageal  opening.  P.  Opening  for  inferior  vena  cava,  round  which  may  be  seen 
three  and  sometimes  four  glands.  Q.  Aortic  orifice  :  the  aorta  has  been  removed  ;  the 
glands  which  lie  on  its  anterior  portion  only  have  been  kept. 

1.  Lymphatic  network  of  the  right  leaflet  of  the  central  portion  of  the  diaphragm. 
2.  Network  of  the  left  leaflet.  3,3.  Network  situated  on  the  edge  of  the  anterior  leaflet; 
this  leaflet  being  hidden  in  man  by  the  pericardium  which  is  closely  adherent  to  it,  its  lym- 
phatic network  can  only  be  injected  from  the  opposite  surface.  In  the  human  subject- 
it  can  only  be  shown  with  great  difficulty,  but  in  mammals  it  can  be  injected  with  ease. 
4,  4,  4.  Glands  in  which  some  of  the  small  trunks  coming  from  the  central  portion  of  the 
diaphragm  end.  5,  5.  Two  glands  situated  over  the  course  of  the  oesophagus,  immediately 
above  the  oesophageal  opening  ;  they  receive  the  vessels  which  come  from  the  inner  por- 
tions of  the  right  and  left  leaflets.  6.  Lymphatic  trunks  which  arise  from  the  posterior 
portion  of  the  right  leaflet  and  right  pillar  of  the  diaphragm  ;  these  trunks,  three  or  four 
in  number,  terminate  in  the  prae-aortic  glands.  7,  7.  Lymphatic  trunks  which  come 
from  the  posterior  portion  of  the  left  leaflet  and  left  pillar  ;  they  pass  to  the  same 
glands  as  the  preceding.  8,  8,  8.  Lymphatic  networks  with  close  and  superposed  meshes, 
which  cover  the  fleshy  portion  of  the  diaphragm.  9,  9,  9,  9,  9,  9,  9.  Lymphatic  trunks 
which  arise  from  a  network  on  the  convex  part  of  the  fleshy  portion  of  the  muscle,  and 
which  then  pass  towards  the  lower  intercostal  spaces  and  end  in  the  aortic  glands. 

10,  10,  10,  10.  Other  smaller  networks  which  run  parallel  to  the  muscles  which  they  sur- 
round ;    all   of   them  converge,   some  running   from  without  inwards,  others   from   within 
outwards,   and  terminate  in.  a  small   trunk  which  ends  in  the  plexus  of  collecting  trunks. 

11,  11,  11,   11.  Plexus  of  collecting  trunks  which  extends  from  behind  forwards  and  ter- 
minates in  a  large  gland  situated  on  the  cartilages  of  the  sixth  and  seventh  ribs.     12.  Gland 
in  which  the  plexus  of  the  collecting  trunks  terminates  :   this  gland  is  single  on  the  right  and 
double  on  the  left  side.     13.  Three  small  glands,  situated  in  front  of  the  pericardium,  and 
to  some  extent  hidden  in  the  surrounding  fat ;  they  receive  some  lymphatic  trunks  which 
traverse  first,  the  suspensory  ligament  of  the  liver,  and  then  the  fleshy  portion  of  the  dia- 
phragm.    From  these  glands  run  several  trunks  which  pass  into  the  gla'ids  on  the  right 
and  left  of  the  xiphoid  cartilage,  over  the  course  of  the  internal  mammary  vessels.      14,  14. 
Glands  in  which  the  preceding  vessels  terminate,  and  which  are  continuous  with  the  plexus 
of  the  collecting  trunks. 

209 


210 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


the  osseous  portion  of  the  seventh  rib.  It  receives  as  afferents 
the  anterior  lymphatic  trunks  of  the  convex  surface  of  the  dia- 
phragm (vide  p.  209).  Its  effe rents,  usually  two  in  number, 
empty  themselves  into  the  inferior  gland  of  the  internal  mammary 
chain.  This  gland  is  always  fairly  large  and  is  rarely  absent 
(Sappey). 

(6)  The  MIDDLE  GROUP  is  formed  by  two  glandular  masses,  one  on 
the  left  and  the  other  on  the  right. 

On  the  left,  these  glands,  three  to  six  in  number,  are  always  some- 
what small,  and  are  grouped  round  the  spot  where  the  phrenic 

nerve  approaches 
the  diaphragm. 
They  are  placed 
on  the  left  of  the 
fibrous  sac  of  the 
pericardium. 

On  the  right, 
their  arrangement 
is  slightly  differ- 
ent. Here  the 
glandular  mass  is 
of  more  impor- 
tance than  that 
of  the  opposite 
side,  and  includes 
two  groups  of 
glands. 

Some,  arranged 
like  the  preced- 
ing, are  placed  ex- 
ternal to  the  peri- 
cardium, to  the 
right  of  the  in- 
ferior vena  cava,  and  round  the  terminal  segment  of  the  right 
phrenic.  Others  are  intra-pericardiac,  and  correspond  to  the 
anterior  surface  of  the  inferior  vena  cava. 

The  middle  diaphragmatic  glands  receive  their  afferent  vessels 
from  the  middle  portion  of  the  diaphragm.  On  the  right  side, 
they  receive  in  addition  numerous  lymphatics  coming  from  the 
liver  (vide  p.  202).  Their  efferent  vessels  pass  into  the  posterior 
mediastinal  glands. 


FIG.  78. — Internal  mammary  glands, 
a.  Efferent  vessel  of  the  internal  mammary  chain.     I,  c. 
Glands  of  this  chain.      d.     Diaphragmatic  gland    (lateral 
mass  of  the  anterior  group). 


LYMPHATICS    OF    THE    THORAX  211 

(c)  The  POSTERIOR  GROUP  comprises  four  or  five  glands  deeply 
situated  between  the  posterior  surface  of  the  pillars  of  the  dia- 
phragm and  the  anterior  surface  of  the  eleventh  and  twelfth  ribs. 
These  glands  are  usually  small  and  are  intermediate  between  the 
ab domino-aortic  glands  and  the  posterior  mediastinal  glands. 

THE  INTERNAL  MAMMARY  GLANDS  (Retro-sternal  glands ; 
praesternal  glands,  Sappey  ;  sternal  glands,  Leaf). — The  internal 
mammary  glands  are  satellites  of  the  vessels  of  this  name,  and 
form  two  ascending  chains,  which  run  parallel  to  the  lateral  borders 
of  the  sternum.  Their  number  is  very  variable.  Four  to  six  are 
usually  present  on  each  side.  The  chain  usually  commences  at 
the  level  of  the  third  space.  At  the  level  of  the  fourth  or  fifth 
space  these  glands  are  almost  always  absent.  Above  the  fourth 
rib  a  single  gland  is  usually  found  in  each  space,  fairly  often  two, 
and  much  more  rarely  three.  The  glands  lie  upon  the  internal 
intercostal  muscle  in  front ;  the  mammary  vessels  are  usually 
posterior  to  them.  Behind  these  vessels,  a  fine  layer  of  cellular 
tissue  separates  the  glands  from  the  mediastinal  pleura.  We  may 
add  that  the  gland  in  the  third  space  is  sometimes  hidden  by  the 
superior  fasciculus  of  the  triangularis  sterni. 

Above  the  first  space,  the  internal  mammary  chain,  which  is 
always  a  satellite  of  the  artery,  runs  like  the  latter  backwards  and 
outwards,  then  becomes  attached  to  the  dome  of  the  pleura  arid 
terminates  at  the  junction  of  the  internal  jugular  and  subclavian 
veins. 

Afferent  Vessels. — The  internal  mammary  glands  collect:  (1)  the 
efferents  of  the  anterior  diaphragmatic  glands  which  themselves 
receive  the  lymphatics  from  the  diaphragm  and  the  liver ; 
(2)  the  lymphatics  from  the  superior  portion  of  the  rectus 
abdominis  muscle ;  (3)  the  lymphatics  from  the  anterior  portion  of 
the  intercostal  spaces  ;  (4)  the  lymphatics  from  the  integuments 
of  the  praesternal  region  ;  (5)  the  lymphatics  from  the  mamma 
(vide  pp.  221  and  222). 

Efferent  Vessels. — Their  efferent  vessels  usually  unite  into  a 
single  trunk  which  empties  itself  into  the  anterior  surface  of  the 
junction  of  the  internal  jugular  and  subclavian  veins.  On  the 
left,  this  trunk  may  also  terminate  in  the  thoracic  duct,  and  on 
the  right,  it  frequently  terminates  in  the  subclavian  trunk.  It  is 
more  unusual  to  see  it  unite  with  the  subclavian  and  the  internal 
jugular  and  form  a  right  lymphatic  trunk  such  as  our  old  authors 
have  described  (vide  p.  291). 


212  SPECIAL    STUDY    OF    THE    LYMPHATICS 

INTERCOSTAL  GLANDS. — These  glands  are  placed  in  the  course  of 
the  intercostal  vessels,  some  of  them  occupy  the  middle  part  of  the 
space  (lateral  glands),  and  others,  the  posterior  portion  (the  pos- 
terior glands). 

The  lateral  glands  are  very  inconstant.  They  are  usually  placed 
at  the  spot  where  the  intercostal  artery  gives  off  its  perforating 
lateral  branch.  They  are  always  very  small,  and  are  really  nothing 
but  simple  interrupting  glandular  nodules  placed  over  the  lymphatic 
trunks  which  come  from  the  external  intercostal  muscles,  and  are 
satellites  of  the  vessels  and  nerves  of  the  intercostal  space  (vide 
further  on.  Lymphatics  of  the  intercostal  muscles,  p.  224). 

The  posterior  glands  are  much  more  important  than  the  preceding. 
They  occupy  the  posterior  extremity  of  the  intercostal  spaces. 
They  usually  correspond  to  the  middle  portion  of  the  neck  of  the 
rib :  more  rarely,  they  are  situated  over  the  costo- vertebral 
articulation.  Behind  they  rest  upon  the  external  intercostal 
muscle,  while  in  front  they  are  covered  by  the  pleura.  Their 
relations  with  the  artery  which  at  this  level  gives  off  its  dorso- 
spinal  branch  are  somewhat  variable  ;  most  frequently,  they  lie 
over  it. 

They  receive  as  afferenis  the  lymphatic  trunks,  satellites  of  the 
aortic  intercostal  arteries.  The  arrangement  of  their  efferent  vessels 
varies  at  different  levels.  The  efferents  of  the  glands  of  the  four 
or  five  lower  spaces  unite  to  form  a  vertical  trunk  which  as  it 
descends  increases  in  size  and  which  terminates  in  the  commence- 
ment of  the  thoracic  duct.  The  efferents  from  the  glands  above 
have  a  transverse  or  ascending  course  and  empty  their  contents 
into  the  upper  portion  of  the  duct.  Sometimes  several  of  these 
trunks  unite  to  form  a  vertical  ascending  trunk  which  terminates 
in  the  thoracic  duct  at  a  point  more  or  less  close  to  its  termination. 

2.    VISCERAL    GLANDS. 

The  visceral  glands  of  the  thorax  which  are  very  numerous  and 
very  important,  may  be  divided  into  three  groups  :  an  anterior 
group,  formed  by  the  glands  in  the  anterior  mediastinum  ;  a  middle 
group,  comprising  the  peritraclieo-broncUal  glands,  situated  at  the 
borders  of  the  anterior  and  posterior  mediastina  ;  and  a  posterior 
group,  formed  by  the  glands  in  the  posterior  mediastinum. 

ANTERIOR  MEDIASTINAL  GLANDS.— The  glands  placed  in  the 
anterior  mediastinum  occupy  its  upper  portion.  They  are  usually 
arranged  in  the  following  manner  :  They  constitute  a  mass  of 


LYMPHATICS    OF    THE    THORAX  213 

from  four  to  six  glands  situated  on  the  anterior  surface  of  the  convex 
surface  of  the  transverse  arch  of  the  aorta.  From  this  prae-  and 
supra-aortic  mass,  glands  detach  themselves  in  chains  which  run 
towards  the  base  of  the  neck.  On  the  right,  these  glands  are  grouped, 
some  in  front  of  the  right  innominate  vein,  others  between  this 
vessel  and  the  innominate  artery,  others  again  behind  the  latter. 
On  the  left,  we  see  these  glands  surrounding  the  left  common  carotid, 
and  the  left  subclavian  vessels,  some  of  them  being  placed  in  front 
of  the  carotid,  others  between  it  and  the  subclavian  :  finallv,  we 
commonly  meet  with  some  of  them  both  on  the  internal  and  external 
surfaces  of  this  vessel. 

Some  authors,  agreeing  with  Barety.  describe  these  glandular 
chains,  which  are  satellites  of  the  large  vascular  trunks,  as  an 
intra-thoracic  prolongation  of  the  deep  cervical  chains.  This  mode 
of  description  does  not  represent  the  real  facts,  for  the  chains  we 
have  just  described  are  ascending  chains  which  run  upwards  to- 
wards the  junction  of  the  internal  jugular  and  subclavian,  in  the 
same  way  as  the  descending  cervical  chains  run  towards  this  same 
junction. 

PERITRACHEO-BROXCHIAL  GLANDS.  —  The  topography  of  the 
peritracheo-bronchial  glands  was  minutely  studied  in  1874  by  Barety , 
whose  description  still  remains  classical.  Agreeing  with  this  author, 
we  may  divide  the  peritracheo-bronchial  glands  into  four  groups, 
viz.  the  right  and  left  praetracheo-bronchial  glands,  and  the  inter  - 
tracheo-bronchial,  and  the  interbronchial  glands. 

1.  The  right  praetracheo-bronchial  glands  are  the  most  important 
of  these  groups  on  account  of  their  number,  the  constancy  of  their 
arrangement  and  the  frequency  of  the  lesions  to  which  they  are 
subject.     They  are  placed  in  the  angle  formed  by  the  trachea  and 
the  right   bronchus.     This  group   usually  comprises  four  or  five 
glands,  which  normally,  are  about  the  size  and  shape  of  a  large 
pea  or  haricot  bean.     These  glands  are  in  relation  :    in  front,  with 
the  inferior  vena  cava  ;    internally,  with  the  trachea  ;    externally, 
with  the  internal  surface  of  the  right  lung  ;    beloiv,  with  the  right 
bronchus,  and  the  right  branch  of  the  pulmonary  artery,  and  the 
terminal  bend  of  the  vena  azygos  major  ;   above,  this  group  reaches 
the  subclavian  arch,  where  it  enters  into  relation  with  the  loop  of 
the  recurrent  laryngeal  nerve  and  the  glandular  chain  which  accom- 
panies it ;   finally,  behind,  it  corresponds  to  the  right  pneumogastric 
nerve. 

2.  The  left  praetracheo-bronchial  glands,  which  vary  from  three 

o 


214 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


to  four  in  number,  are  usually  smaller  than  the  preceding.     They 

are  in  relation,  in 
front,  with  the  as- 
cending portion  of 
the  aortic  arch ; 
internally,  with  the 
trachea;  &e/<m\with 
the  left  bronchus, 
and  with  the  left 
pulmonary  arcery ; 
externally,  with  the 
left  lung  ;  behind, 
with  the  left  pneu- 
mogastric.  Above, 
they  enter  into 
relation  with  the 
horizontal  portion 
of  the  aortic  arch 
and  with  the  loop 
of  the  recurrent 
laryngeal  nerve 
where  they  are  con- 
tinuous with  the 
glandular  chain 
accompanying  this 
nerve. 

3.  The  intertra- 
clie  o-b  r  oncliial 
glands  are  placed 
in  the  angle  of 
bifurcation  of  the 
trachea.  This  un- 
even and  mesially 
placed  group  com- 
prises from  ten 
to  twelve  glands, 
which  are  usually 
more  numerous 
and  larger  under 
They  are  in  relation  : 
in  front,  with  the 


Fro.  79. — Arrangement  and  connections  of  the  tracheo-bron- 
chial  glands  (from  a  drawing  by  Halle  and  borrowed  from 
vol.  iv.  of  La  Clinique  Medicate,  by  H.  Gueneau  de  Mussy). 

1.  Oesophagus.  2.  Trachea.  3.  Innominate  nrtery.  4. 
Arch  of  the  aorta.  5.  Left  subclavian  artery.  6.  Left  com- 
mon carotid  artery.  7.  Thoracic  aorta.  8.  Oesophagus.  9. 
Right  bronchus.  10.  Left  bronchus.  11.  Right  pneumo- 
gastric  nerve.  12.  Right  recurrent  nerve.  13.  Bronchial 
filaments  of  right  pneumogastric.  14.  Anastomotic  filaments. 
15.  Oesophageal  filaments.  16.  Left  pneumogastric  nerve. 
17.  Left  recurrent  laryngeal  nerve.  18.  Bronchial  filaments 
of  left  pneumogastric.  19.  Anastomotic  filaments.  20. 
Glandular  chain  of  right  recurrent  nerve.  21.  Glandular 
chain  of  left  recurrent  nerve.  22.  Right  praebracheo- 
bronchial  group.  23.  Left  praetracheo-bronchial  '  group. 
24,  25.  Right  and  left  interbronchial  groups.  26.  Intertra- 
cheo -bronchial  group. 

the  right  than    under  the  left  bronchus. 
above,    with    the    bifurcation    of    the   trachea 


LYMPHATICS    OF    THE    THORAX  215 

pericardium  which  separates  them  from  the  left  auricle  to  which 
they  send  a  small  venous  tributary,  which  was  observed  by  Lanne- 
longue,  and  again  found  by  Baroty  ;  behind,  with  the  pulmonary 
plexus  and  the  anterior  surface  of  the  oesophagus. 

4.  The  interbronchial  glands  occupy  the  angles  of  division  of  the 
larger  bronchi.  According  to  Cruveilhier,  glands  may  be  found 
even  in  the  divisions  of  the  fourth  order.  These  glands,  completely 
buried  in  the  pulmonary  parenchyma,  are  in  intimate  relation  with 
the  branches  of  the  pulmonary  vessels  and  more  particularly  with 
those  of  the  pulmonary  artery,  which  they  may  compress  when 
hypertrophied. 

The  peritracheo-bronchial  glands  are  often  enlarged,  as  a  result 
of  the  frequent  infections  to  which  they  are  exposed.  From  the 
earliest  years  of  life  they  present  a  blackish  tint,  due  to  the  fact  that 
they  arrest  the  particles  of  carbon  collected  by  the  leucocytes  on 
the  surface  of  the  bronchi.  This  normal  anthracosis  is  accom- 
panied by  a  progressive  sclerosis  which,  in  old  people,  transforms 
these  glands  into  simple  fibrous  blocks. 

POSTERIOR  MEDIASTIXAL  GLANDS. — The  posterior  mediastinal 
glands  are  scattered  round  the  oesophagus.  They  are  usually 
placed  on  the  anterior  surface  of  this  tube,  behind  the  pericardium. 
Though  it  is  more  rare,  we  may  also  come  across  two  or  three  small 
retro- oesophageal  glands,  situated  by  the  side  of  the  thoracic  duct. 

BIBLIOGRAPHY. — Sur  les  ganglions  peritracheo-bronchiques  voy.  :  BECKER. 
De  glandulis  thoracis  lymphaticis  atque  thymo.  These  Berlin,  1827. — BARETY 
De  1'adenopathie  tracheo-bronchique.  These  Paris.  1874. — GUEXEAU  DE 
MUSSY.  Clinique  medicate,  t.  IV,  1885.— LEAF,  loc  .cit.,  p.  28  et  Fig.  2,  3,  4 
et  5. 

§  2.  LYMPHATIC  VESSELS  OF  THE  THORAX. 

WE  will  study  in  turn  (1)  the  lymphatic  vessels  of  the  walls  of  the 
thorax,  and  (2)  those  of  the  intra-thoracic  viscera. 

1.  PARIETAL  LYMPHATIC  VESSELS. 

The  parietal  lymphatics  may  be  divided  into  :  cutaneous  lym- 
phatics, lymphatics  of  the  mammary  gland,  lymphatics  of  the 
perithoracic  muscles,  lymphatics  of  the  intercostal  muscles,  and 
finally,  lymphatics  of  the  diaphragm. 

CUTANEOUS  LYMPHATICS. — The  integuments  of  the  thorax  may 
be  divided  into  three  lymphatic  territories  :  viz.  anterior,  lateral 
and  posterior.  This  division  is  artificial,  in  the  sense  that  the  three 
territories  are  far  from  possessing  distinct  limits,  but  it  has  the 


216  SPECIAL    STUDY    OF    THE    LYMPHATICS 

advantage  of   enabling  us  to  classify  more  clearly  the  collecting 

trunks  of  the  cutaneous  network  of  the  thorax. 

(1)  ANTERIOR   TERRITORY.— The   anterior  territory  extends  from 

the  median  line  to  the  neighbourhood  of  the  anterior  axillary  line. 

We  must  notice 
that  we  cannot  in- 
clude in  this  region 
the  lymphatics  of 
the  integuments 
which  cover  the 
central  portion  of 
the  mamma. 
These  vessels  have 
a  special  ar- 
rangement which 
will  be  studied 
with  the  lym- 
phatics of  the 
mammary  gland. 
The  collecting 
trunks  which  drain 
the  anterior  terri- 
tory appear  in  the 
region  of  the 
median  line.  They 
run  towards  the 
axilla,  passing 
some  above,  and 
some  below  the 

FIG.  80. — Lymphatic  vessels  of  the  antero-lateial  portions  of  TTT 

the  thorax  (Sappey).  breast.      We  may 

1,  1.    Axillary    glands.     2,    2.    Superficial    lymphatic    trunks  here    remark     that 
of    the   upper  limb.      3,  3.  Large  trunks  which  also  come  from   -f     •  +    11T,11011Q1 

,.  -,  Tl_l_.il_''L-jj£  J        lt»        lo        JlUu       UllllbUCvI 

the  integuments  of  the  upper  limb,  but  which,  instead   of  end- 
ing in    the  glands  of    the  axilla,  run  in  the  space  between  the  to        S66          trunks 
deltoid  and  pectoralis  major,  and  terminate  in  a  sub-  clavicular       1-1 
gland.     4.  A  gland  which  is  sometimes  seen  in  the  course  of  this  WlllCll  arise    SOme- 
trunk.     5,  6.  Lymphatic  vessels  of    the   anterior  superior   part  -yyhat  low  down    in 
of  the  thorax.     6,  6,  7,  7.  Lymphatic  vessels  which  start  from 
the  integuments  of  the  thorax.  the  neighbourhood 

of  the  xiphoid  car- 
tilage, for  instance,  describe  a  very  well  marked  curve  and  pass 
above  the  breast  to  reach  the  axilla.  All  these  anterior  trunks 
terminate  in  the  thoracic  group  of  axillary  glands. 

Mascagni  figures  in  the  course  of  one  of  these  trunks,  two  small  glands 


LEVEILLE   OEu 


-3/EflMOflCKEN 


LYMPHATICS    OF    THE    THORAX  217 

placed  near  the  inferior  border  of  the  pectoralis  major,  at  the  level  of  the 
nipple  line.  These  glands  are  simple  interrupting  glandular  nodules,  and 
are  usually  absent.  They  must  not  be  confounded  with  the  paramammillary 
glands,  described  by  Gerota,  and  to  which  we  shall  have  to  return  later  on 
(vide  Mascagni,  loc.  cit.,  tab.  xxiv.  68). 

This  homolateral  axillary  channel  represents  the  principal  lym- 
phatic channel  of  the  anterior  region  of  the  thorax,  but  accessory 
channels  exist  which  we  must  shortly  mention. 

Thus  some  trunks  arise  below  the  clavicle  and  run  upwards  and 
outwards,  and  passing  above  this  bone,  terminate  in  the  supra- 
clavicular  glands.  Similarly,  when  an  injection  is  made  at  a  little 
distance  from  the  middle  line,  the  injected  mass  may  be  observed 
to  pass  into  the  glands  of  the  opposite  side.  Now  this  route  is 
rendered  possible  not  only  in  consequence  of  the  absence  of  inter- 
ruption between  the  networks  of  origin  on  either  side  of  the  middle 
line,  but  also  on  account  of  some  of  the  trunks  having  a 
crossed  origin.  It  is  true  that  this  discussation  of  the  collecting 
trunks  is  not  to  be  regarded  as  normal ;  Oelsner  has  only  met  with 
it  twice  in  nine  subjects.  Finally,  in  the  neighbourhood  of  the 
middle  line  we  may,  by  injecting  the  cutaneous  network,  fill  two 
or  three  collecting  trunks  which  perforate  the  anterior  extremity 
of  the  intercostal  spaces,  and  which  closely  accompany  the  per- 
forating branches  of  the  internal  mammary  artery  and  reach  the 
satellite  glands  of  this  artery.  We  are  here  dealing  with  an  arrange- 
ment, which,  if  not  constant,  is  at  least  very  frequent,  if  we  may 
judge  by  our  own  observations. 

To  sum  up,  the  cutaneous  territory  of  the  anterior  region  of  the 
thorax  possesses  a  principal  lymphatic  channel,  the  homolateral 
axillary  channel,  and  three  accessory  channels,  viz.  the  contra- 
lateral,  the  subclavian  and  the  internal  mammary. 

When,  on  account  of  an  embolus  in  or  neoplastic  thrombosis  of 
the  lymphatic  vessels,  the  chief  axillary  channel  becomes  obstructed, 
the  accessory  channels  which  we  have  j  ust  been  considering  may  be- 
come of  greater  importance.  We  may  then  even  see  channels 
appear  which  are  quite  abnormal. 

Thus,  in  a  case  of  this  kind,  Gerota  has  seen  the  skin  of  the  sub- 
mammarv  region  send  out  its  lymphatics  into  the  superficial  inguinal 
glands  and  even  into  the  external  iliac  glands,  by  means  of  trunks 
which  became  deeply  placed,  and  embraced  the  deep  epigastric 
artery. 

This  knowledge  of  the  mode  of  termination  of  the  lymphatics 
of  the  integuments  of  the  anterior  region  of  the  thorax  is  of  great 


218  SPECIAL    STUDY    OF    THE    LYMPHATICS 

practical  importance.  When  an  epithelioma  of  the  breast  has 
reached  a  slightly  advanced  state  of  development,  usually  the 
invasion  is  not  limited  to  the  skin  of  the  mammary  region,  but 
also  extends  into  the  peri-mammary  integuments.  As  Oelsner 
remarked,  it  is  therefore  almost  as  essential  to  be  acquainted  with 
the  arrangement  of  the  lymphatics  of  the  integuments  as  with 
those  of  the  gland  itself. 

2.  LATERAL    TERRITORY. — In  the    lateral  territory  arise  five  or 
six  trunks  which  ascend  vertically,  perforate  the  axillary  aponeu- 
rosis  and  terminate,  as  do  the  anterior  trunks,  in  the  thoracic  group 
of  axillary  glands. 

3.  POSTERIOR   TERRITORY. — The  posterior    territory  gives  origin 
to  ten  or  twelve  trunks  (Sappey).     The  lower  trunks  appear  a  little 
below  the  inferior  border  of  the  thorax.     The  middle  trunks  arise 
near  the  middle  line  throughout  the  dorsal  region.     The  upper 
trunks   spring  from   the   lower  part   of   the   neck.     All   converge 
towards  the  axilla,  thus  presenting  in  their  entirety  a  somewhat 
regular  radial  arrangement  (vide  Fig.  81).     They  terminate  in  the 
scapular  group  of  axillary  glands. 

LYMPHATICS  OF  THE  BREAST. — We  will  divide  the  lymphatics  of 
the  breast  into  cutaneous  and  glandular. 

1.  THE  CUTANEOUS  LYMPHATICS. — The  arrangement  of  cutaneous 
lymphatics  varies  at  the  periphery  and  at  the  centre  of  the  mam- 
mary region,  i.e.  in  the  region  of  the  areola  and  the  nipple. 

The  peripheral  cutaneous  lymphatics  are  in  no  way  distinguishable 
from  the  cutaneous  lymphatics  of  adjacent  regions  ;  they  terminate 
in  collecting  trunks  which  carry  the  lymph  from  the  integu- 
ments of  the  anterior  portion  of  the  thorax.  Those  which  arise 
from  the  internal  part  of  the  gland  may  end  in  the  axillary  glands 
of  the  opposite  side  (Rieffel,  Oelsner). 

The  central  cutaneous  lymphatics  have,  on  the  contrary,  from  the 
point  of  view  of  their  origin  and  termination,  a  very  peculiar  arrange- 
ment. At  their  origin,  they  form  a  network  with  extremely  fine 
meshes,  arranged  in  several  planes  which,  especially  -in  the  female 
subject  who  has  died  during  a  state  of  lactation,  it  Is  easy  to  inject. 
When,  by  using  mercury,  we  succeed  in  entirely  filling  this  sub- 
areolar  and  sub-mammillary  network,  all  the  central  part  of  this 
region  seems  transformed  into  a  silvered  plate,  and  an  examination 
with  a  lens  is  necessary  to  distinguish  the  meshes  of  which  it 
is  composed.  From  this  network,  run  numerous  trimklets  which 
pass  immediately  into  a  lymphatic  plexus,  formed  by  larger  trunks  : 


LYMPHATICS    OF    THE    THORAX 


219 


FIG.  81. — Cutaneous  lymphatics  of  the  pluteal  region  and  the  dorsal  surface  of  tho 

trunk  (Sappey). 

1,  1.  Lymphatic  vessels  of  the  internal  portion  of  the  gluteal  region,  running  downwards, 
inwards,  and  then  forwards,  to  join  those  from  the  anus  and  perineum  ;  like  the  latter,  they 
terminate  in  the  internal  glands  of  the  inguinal  region.  2,  2.  Lymphatic  trunks  which 
spring  from  the  outer  and  upper  two-thirds  of  the  thigh  :  all  these  trunks  are  directed 
upwards  and  outwards,  they  then  turn  round  the  vipper  part  of  the  limb  to  terminate  in 
the  external  glands  of  the  inguinal  region.  3,  3.  Branchlets  which  form  junctions  between 
the  ascending  and  descending  vessels  of  the  gluteal  region.  By  pricking  the  skin  with  the 
point  of  a  syringe  in  this  region  which  is  common  to  the  two  groups  of  vessels,  sometimes 
one,  sometimes  the  other  set  of  vessels  may  be  injected.  4,  4.  Median  lymphatic  network 
of  the  lumbar  region.  This  network,  like  all  others  of  the  some  kind,  does  not  correspond 


220  SPECIAL    STUDY    OF    THE    LYMPHATICS 

to  any  lymphatic  trunk  on  its  deep  aspect.  The  latter  spring  from  the  right  and  left  of  its 
lateral  parts.  Mascagni  committed  an  error  in  stating  that  the  lymphatic  vessels  of  the 
right  side  of  the  lumbar  and  dorsal  regions  might  arise  from  the  left  side  and  vice  versa. 
This  error  is  attributable  to  the  very  defective  mode  of  study  which  was  then'  in  vogue. 
In  no  part  of  the  trunk  or  head,  have  I  seen  any  vessel  spring  from  the  side  opposite  to 
that  to  which  it  belonged.  5,  5,  5.  Trunks,  six  to  eight  in  number,  which  run  from  this 
network  and  converge  from  behind  forward.  6,  6,  These  same  trunks  which  turn  round 
the  left  flank  to  terminate  in  the  glands  of  the  inguinal  region.  7,  7,  7.  Lymphatic  vessels 
of  the  lateral  walls  of  the  thorax,  which  are  directed  from  below  upwards  towards  the 
axillary  glands.  8,  8,  8,  8,  8.  Lymphatic  trunks  springing  from  a  network  common  to 
them  and  to  those  of  lumbar  region.  9,  9.  Median  lymphatic  network  of  the  dorsal  region. 
JO,  10,  10,  10,  10.  Trunks  whose  primary  radicals  come  from  this  network  and  run  from 
within  outwards.  11,  11.  Median  lymphatic  network  of  the  posterior  part  of  the  neck.  12, 
12,  12,  12.  Trunks  which  come  from  this  network  ;  they  converge  from  within  outwards,  run. 
ning  obliquely  over  the  posterior  and  superior  part  of  the  shoulder  ;  they  then  join  those 
from  the  dorsal  region  to  terminate  in  the  glands  of  the  axilla,  lit,  13.  Collection  of  trunks 
which  take  their  origin  from  the  posterior  portion  of  the  thorax.  They  turn  round  the 
posterior  border  of  the  axilla  to  terminate  in  the  glands  of  this  region.  14,  14,  14.  Vessels, 
from  the  posterior  and  superior  portion  of  the  arm,  also  converging  to  the  axilla  to  terminate 
like  the  preceding.  15,  15.  Two  trunks  of  the  posterior  part  of  the  neck  which  turn  round 
the  superior  border  of  the  trapezius  muscle  to  end  in  the  supra-clavicular  glands. 

this  is  the  sub-areolar  plexus  of  Sappey,  in  which  the  majority  of 
trunks  coming  from  the  mammary  gland  itself,  also  terminate. 

2.  THE  LYMPHATICS  OF  THE  MAMMARY  GLAXD. — We  will  not  no \v 
approach  the  disputed  question  as  to  the  origin  of  the  lymphatics 
of  the  mammary  gland  (vide  on  this  point  vol.  v.  p.  697 1).  Moreover, 
the  researches  of  Regaud  seem  to  have  settled  the  question. 

In  the  glandular  lobules,  the  lymphatics  arise  from  large  peri- 
lobular  sacs  ;  these  never  penetrate  into  the  interior  of  the  lobules, 
but  simply  ramify  on  their  surface  to  a  greater  or  less  extent.  In 
the  galactophorous  ducts,  the  network  of  origin  is  formed  by  capil- 
laries whose  general  direction  is  parallel  to  the  excretory  ducts,  and 
which  unite  with  each  other  by  transverse  anastomoses. 

From  the  peri-lobular  sacs  spring  two  kinds  of  collecting  trunks, 
some  of  which  reach  the  sub-areolar  plexus  and  thence  pass  to  the 
axillary  glands.  They  constitute  the  principal  lymphatic  channel 
of  the  breast.  Others  emerge  from  the  periphery  of  the  gland,  and 
form  several  accessory  channels  which  vary  in  their  course  and 
termination. 

A.  THE  PRINCIPAL  LYMPHATIC  CHANNEL. — This  channel  is  the 
only  one  described  by  Sappey,  whose  description  has  been  adopted 
by  Richet,  Tillaux,  Merkel,  Nagel,  Pierre  Delbet,  Sorgius.  The 
collectors  of  which  it  is  composed  start  from  the  peri-lobular  sacs. 
They  run  towards  the  nipple,  and  passing  between  the  galacto- 
phorous ducts  collect  as  they  go  the  capillaries  attached  to  these 
ducts.  They  terminate  in  the  sub-areolar  plexus. 

This  plexus,  in  which,  as  we  have  already  seen,  the  cutaneous 
lymphatics  of  the  areola  and  nipple  terminate,  is  formed  by  large 

1  Treatise  of  Human  Anatomy,  Porrior  and  Charpy. 


LYMPHATICS    OF    THE    THORAX 


221 


embossed  trunks.  The  entire  plexus  resembles  a  disc  perforated 
at  its  centre  by  an  orifice  which  circumscribes  the  base  of  the  nipple. 
The  periphery  of  this  disc  usually  extends  beyond  the  edge  of  the 
areola. 

.From  this  plexus  usually  run  two  large  trunks  which  leave  it,  the 


3     3 


FIG.  82. — Lymphatic  vessels  of  the  anterior  surface  of  the  breast ;  the  sub-areolar 

plexus  and  the  trunks  which  run  from  it  (Sappey). 

1,  1.  Lymphatic  network  of  the  anterior  surface  of  the  mammary  gland.  2,  2.  Lobules 
of  the  gland,  the  peripheral  network  of  which  has  not  been  injected  in  order  that  the  cir- 
cumlobular  network  which  encircles  it  may  be  seen.  3,  3,  3,  3.  Trunks  which  arise  from  the 
upper  and  lower  parts  of  the  gland.  4,  4.  Sub-areolar  lymphatic  plexus.  5.  Lymphatic 
vessel  which  arises  from  the  inner  part  of  this  plexus.  6.  Vessel  arising  from  the  oxiter 
part  of  the  same  plexus.  7.  Vessel  coming  from  the  lower  part  of  the  gland  ;  after  n  long 
course  it  unites  with  the  preceding  to  form  one  of  two  trunks  in  which  all  the  others  end. 
8,  8.  The  two  principal  lymphatic  trunks  which  extend  transversely  from  the  mamma  to 
the  axillary  glands. 

one  on  its  internal,  the  other  on  its  external  part.  The  internal 
trunk  runs  at  first  downwards,  and  then  outwards,  turning  round 
the  inferior  border  of  the  sub-areolar  plexus.  It  is  thus  directed 
towards  the  axilla,  and  runs  in  the  subcutaneous  cellular  tissue, 
along  the  lower  border  of  the  pectoralis  major,  which  it  crosses  at 
the  level  of  the  third  rib  to  reach  the  base  of  the  axilla.  This 

o* 


222  SPECIAL    STUDY    OF    THE    LYMPHATICS 

collecting  trunk  constantly  receives  as  affluents,  one  or  two  fair- 
sized  trunks  coming  directly  from  the  inferior  portion  of  the  mam- 
mary gland.  The  external  trunk,  which  is  usually  smaller  than  the 
preceding,  runs  directly  outwards  towards  the  axilla.  Before  it 
reaches  the  latter  it  is  augmented  by  a  vessel  coming  from  the 
superior  part  of  the  gland. 

At  the  base  of  the  axilla,  these  two  collecting  trunks  perforate 
the  axillary  aponeurosis  and  terminate  in  one  or  two  glands,  placed 
on  the  inner  wall  of  the  axilla  on  the  third  digitation  of  the  serratus 
magnus. 

These' glands  (the  principal  regional  glands  of  the  breast)  may  or 
may  not  be  covered  by  the  lower  part  of  the  pectoralis  major  according 
to  the  muscular  development  of  the  subject  (Sorgius).  j  They  con- 
stitute the  supero-internal  group  of  the  thoracic  chain  of  axillary 
glands  (the  anterior  thoracic  lymph  glands,  Oelsner)  (vide  further 
on  :  Topography  of  axillary  glands,  pp.  234  and  235).  On  the  course 
of  these  collecting  trunks  may  sometimes  be  found  a  little  interrupt- 
ing'glandular  nodule  (Schaltdriise)  ;  this  is  the  paramammary  gland 
of  Sorgius. 

We  must  recollect"  here  that  the  glands  in  which  the  emissaries  of  the 
sub-areolar  plexus  end,  send  their  efferents  into  the  central  axillary  glands, 
and  by  means  of  the  latter,  into  the  subclavian  glands  ;  but  these  efferents 
may  also  end  directly  in  the  subclavian  or  in  the  other  glandular  groups  of 
the  axilla,  viz.  the  humeral  or  scapular  group.  Further,  Nagel  has  seen 
one  of  the  collectors  coming  from  the  sub-areolar  plexus,  send  a  branch  to  a 
humeral  gland,  before  itself  terminating  in  the  supero-internal  thoracic 
glands.  Similarly  Grossmann,  and  Rieffel  have  seen  a  mammarjr  collecting 
trunk  pass  directly  into  the  subclavian  glands.  In  cancer  of  the  breast,  we 
must  regard  all  the  glands  of  the  axilla  with  suspicion  (for  further  details, 
vide  Axillary  Glands,  pp.  234  and  235). 

B.  ACCESSORY  CHANNELS.— The  accessory  channels  are  three  in 
number,  viz.  the  axillary,  the  subclavian,  and  the  internal  mammary. 

(a)  The  Accessory  Axillary  Channels. — This  has  been  well 
described  by  Gerota.  It  comprises  1  to  3  collectors  which  detach 
themselves  from  the  inferior  part  of  the  mamma  and  directly  reach 
the  axillary  glands.  These  vessels  may  present  in  their  course 
small  glandular  nodules,  which  are  however  often  absent  (para- 
mammillary  lymph  glands  of  Gerota).  This  accessory  axillary 
channel  is  inconstant ;  in  fact,  the  trunks  which  compose  it  often 
empty  their  contents  into  the  principal  lymphatic  channel.  More- 
over it  is  not  of  much  practical  importance. 

We  may  compare  this  channel  to  the  trunks  described  by  Heidenhain. 
This  'author  admits  the  existence  of  collecting  trunks  which  detach  them- 
selves from  the  posterior  surface  of  the  gland,  and  run  within  the  pectoral 


LYMPHATICS    OF    THE    THORAX 


223 


fascia  to  gain   the  axillary  glands.     We  must  observe  that  Heidenhain's 
description  is  only  based  on  the  examination  of  pathological  specimens. 

(b)  The    Subclavian   Channel. — Grossmann    has    injected    three 
times  in  thirty  subjects,  a  trunk  which  detached  its3lf  from  the 


FIG.  83. — Lymphatics  of  the  breast  and  axillary  glands  (semi-diagram  mitic). 

1.  Delto-pectoral  gland.  2,  2.  Glands  of  the  humeral  chain.  3,  3.  Glands  of  the  central 
group  and  the  scapular  chain.  4,  4.  Glands  of  the  thoracic  chain  (supero-internal  group). 
5,  Gland  of  the  thoracic  chain  (infero-external  group).  6.  Subclavian  glands.  7.  Mam- 
mary lymphatic  ending  in  the  Subclavian  glands  (inconstant).  8,  9.  Mammary  collecting 
trunks,  ending  in  glands  of  the  thoracic  chain.  10.  Sub-areolar  plexus.  11.  Cutaneous 
collecting  trunk  of  the  lateral  walls  of  the  thorax.  12,  13.  Mammary  collecting  trunks 
about  to  end  in  the  internal  mammary  glands. 

posterior  surface  of  the  mamma,  then  perforated  the  pectoralis 
major,  and  running  between  this  muscle  and  the  pectoralis  minor 
reached  the  subclavian  glands.  This  trunk  was  a  satellite  of  the 
superior  thoracic  artery  (thoracic  branch  of  the  acromio-thoracic  ?), 
and  presented  in  its  course  two  or  three  small  glandular  nodules 
(retro-pectoral  glands). 

Hotter,  basing  his  statements  on  the  examination  of  specimens  of  cancer 
of  the  breast,  admits  the  existence  of  this  channel  described  by  Grossmann. 
According  to  the  author,  the  retropectoral  glands  exist  in  nearly  half 
the  cases  and  are  situated  not  only  in  the  course  of  the  thoracic  branch  of  the 
acromio-thoracic  artery,  but  also  along  the  branch  which  the  external 


224  SPECIAL    STUDY    OF    THE    LYMPHATICS 

mammary  sends  to  the  pectoralis  major.     We  will  return  to  these  glandular 
nodules  when  studying  the  axillary  glands. 

(c)  The  Internal  Mammary  Channel. — The  internal  mammary 
channel  is  much  more  important  than  the  preceding.  Its 
presence  was  formally  denied  by  Sappe}^  though  it  was  observed 
a  long  time  ago  by  Mascagni  and  Cruikshank.  Henle  mentions 
it  incidentally.  More  recently  Stiles,  Schaffer,  Symington,  Gerota 
Poirier,  Rieffel,  and  Oelsner  have  definitely  proved  its  existence. 
The  trunks  which  constitute  this  channel  arise  from  the  inner 
extremity  of  the  mamma  :  they  follow  the  course  of  the  arterioles 
given  off  by  the  internal  mammary  artery  to  the  gland.  Like  the 
latter,  they  perforate  the  pectoralis  major  and  the  internal  inter- 
costal muscles,  and  empty  themselves  into  the  glands  of  the  mam- 
mary chain.  Rotter  saw  a  small  glandular  nodnle  within  the  fibres 
of  the  great  pectoral  lying  on  one  of  these  vessels. 

The  lymphatics  of  the  breast,  which  are  tributaries  of  the  internal  mammary 
chain,  may  reach  the  above-mentioned  glands  by  taking  a  very  different 
course  to  that  we  have  just  indicated.  Thus  Oelsner  has  seen  some  small 
collectors  running  from  the  inferior  border  of  the  mamma  which,  after 
traversing  the  great  pectoral,  entered  the  thorax  through  the  fourth  inter- 
costal space,  at  the  level  of  the  costo-chondral  articulation.  These  vessels 
then  resolved  themselves  into  a  single  trunk  which  terminated  in  a  gland 
belonging  to  the  internal  mammary  chain,  after  presenting  in  its  course  a 
glandular  nodule,  placed  about  the  centre  of  the  fourth  costal  cartilage.  One 
of  the  present  writers  has  twice  met  with  an  arrangement  identical  with  that 
described  by  Oelsner. 

It  is  important  to  remark  that  we  must  not  exaggerate  the  importance  of 
this  internal  mammary  channel.  Though  its  presence  is  anatomically  in- 
disputable, facts  none  the  less  show  that  in  the  early  stages  of  cancer  of  the 
breast,  the  invasion  of  the  retro-sternal  glands  is  exceptional.  The  fact 
that  these  glands  are  not  usually  involved  is  probably  to  be  explained  by 
the  atrophy  of  this  channel  in  senile  mammae,  in  which  cancer  usually 
develops. 

BIBLIOGRAPHY. — MASCAGNI,  loc.  cit.,  tab.  XXIV. — SAPPEY,  loc.  cit., 
pi.  XIII,  Fig.  13,  et  p.  48. — SORGIUS.  Ueber  die  Lymphgefasse  der  weiblichen 
Brustdriise,  Dissert.  Strassburg,  1880. — HEIDENHAIN.  Ueber  die  Ursachen 
der  localen  Krebsrecidive  nach  Amputatio  Mammae  Langenbectts  Arch., 
XXXIX,  1889. — RIEFFEL.  De  quelques  points  relatifs  aux  recidives  et  aux 
generalisations  des  cancers  du  sein  chez  la  femme.  These  Paris,  1890. — 
GROSSMANN.  Ueber  die  Lymphdriisen  und  -bahnen  der  Achselhohle.  Berlin, 
1893. — GEROTA.  Nach  welchen  Richtungen.  kann  sich  der  Brustkrebs  weiter- 
verbreiten  ?  Archiv  f.  klin.  Chir.  LIV,  1897. — ROTTER.  Zur  Topographic 
des  Mammacarcmomes.  Arch.  f.  klin.  Chir.  LVIII,  2,  1899. — L.  (ELSNER. 
Anatomische  Untersuchung  iiber  die  Lymphwege  der  Brust,  etc.  Arch.  /. 
klin.  Chir.,  1901,  LXI,  1,  p.  134. 

LYMPHATICS  OF  THE  THORACIC  MUSCLES.— The  lymphatics  of  the 
muscles  attached  to  the  external  surface  of  the  thorax  end  in  the 


LYMPHATICS    OF    THE    THORAX  225 

axillary  glands.  The  lymphatics  of  the  great  pectoral  alone  merit  a 
special  description  on  account  of  the  frequent  invasion  of  this  muscle 
during  the  progress  of  cancer  of  the  breast.  These  lymphatics  have 
been  recently  thoroughly  studied  by  Oelsrier.  They  arise  from  cellular 
septa  which  ramify  over  the  muscle,  and  are  divided  into  several 
groups.  Some  run  towards  the  subclavian  glands,  accompanying  the 
thoracic  branch  of  the  acromio-thoracic  artery.  Others  accompany 
the  pectoral  branch  of  the  external  mammary  artery  and  end  in  the 
thoracic  group  of  axillary  glands.  All  these  trunks  present  in  their 
course  small  glandular  nodules  (Grossmann,  Rotter)  to  which  we 
have  already  alluded  when  studying  the  lymphatics  of  the  breast. 
Finally,  there  are  other  trunks  which  end  in  the  glands  of  the 
internal  mammary  chain. 

It  follows  from  this  arrangement  of  the  lymphatics  of  the  great  pectoral 
that,  even  if  we  reject  the  existence  of  mammary  lymphatics  ending  in  the 
retro-pectoral  and  in  the  internal  mammary  glands,  we  ought  nevertheless 
to  regard  the  invasion  of  these  glands  as  possible,  when  the  growth  of  the 
breast  is  adherent  to  the  pectoralis  major.  As  far  as  the  inter-pectoral  glands 
are  concerned,  Hotter  has  several  times  observed  their  infection. 

LYMPHATICS  OF  THE  INTERCOSTAL  MUSCLES. — We  must  distinguish 
between  the  lymphatics  of  the  internal  and  those  of  the  external 
intercostal  muscles.  These  two  groups  differ,  in  fact,  not  only  in 
their  origin,  but  also  in  their  course  and  termination  (Sappey). 

The  lymphatics  which  spring  from  the  internal  intercostals  give 
origin  to  obliquely  ascending  branches,  which  pass  into  a  trunk 
which  runs  along  the  lower  border  of  the  supra- jacent  rib,  travelling 
in  the  sub-pleural  cellular  tissue.  There  is  a  trunk  for  each  inter- 
costal space.  They  all  run  forwards.  The  trunks  from  the  six  or 
eight  upper  spaces  terminate  singly  in  the  glands  of  the  internal 
mammary  chain  or  in  the  lymphatics  uniting  these  glands.  The 
trunks  of  the  lower  spaces  usually  fuse  into  a  single  trunk  which 
reaches  the  lower  portion  of  the  mammary  chain.  The  internal 
intercostal  lymphatics  receive  the  lymphatics  of  the  parietal  pleura. 

The  lymphatics  which  spring  from  the  external  intercostal  muscles 
are  much  more  developed  than  the  preceding  (Sappey).  They  give 
rise  to  trunks  which  run  backwards,  accompanying  the  vessels  and 
nerves  in  the  space.  These  trunks  terminate  in  the  posterior 
intercostal  glands.  We  have  observed  that  they  frequently  present 
in  their  course  small  glandular  nodules,  variable  in  number  and 
arrangement,  which  we  have  termed  the  lateral  intercostal  glands. 
The  external  intercostal  lymphatics  receive  some  small  branches 
which  accompany  the  perforating  branches  of  the  intercostal 


10       -; 


•  L 


FIG.  84. — Lymphatics  of  the  superior  surface  of  the  diaphragm  (Sappey). 

A.  Xiphoid  cartilage.  B,  B.  Fifth  rib.  C,  G.  Sixth  rib.  D,  D.  Seventh'  rib. 
E.  Eighth  rib.  P.  Ninth  rib.  G.  Tenth  rib.  H.  Eleventh  rib.  K.  Twelfth  rib. 
L,  L,  L,  L.  Right  and  left  halves  of  the  muscular  portion  of  the  diaphragm.  M,  M.  Pillars 
of  the  diaphragm.  N.  Central  aponeurotic  portion  of  the  diaphragm  with  its  three  leaflets. 
O.  Oesophageal  opening.  P.  Opening  for  inferior  vena  cava,  round  which  may  be  seen 
three  and  sometimes  four  glands.  Q.  Aortic  orifice  :  the  aorta  has  been  removed  ;  the 
glands  which  lie  on  its  anterior  portion  only  have  been  kept. 

1.  Lymphatic  network  of  the  right  leaflet  of  the  central  portion  of  the  diaphragm. 
2.  Network  of  the  left  leaflet.  3,  3.  Network  situated  on  the  edge  of  the  anterior  leaflet  ; 
this  leaflet  being  hidden  in  man  by  the  pericardium  which  is  closely  adherent  to  it,  its  lym- 
phatic network  can  only  be  injected  from  the  opposite  surface.  In  the  human  subject 
it  can  only  be  shown  with  great  difficulty,  but  in  mammals  it  can  be  injected  with  ease. 
4,  4,  4.  Glands  in  which  some  of  the  small  trunks  coming  from  the  central  portion  of  the 
diaphragm  end.  5,5.  Two  glands  situated  over  the  course  of  the  oesophagus,  immediately 
above  the  oesophageal  opening  ;  they  receive  the  vessels  which  come  from  the  inner  portions 
of  the  right  and  left  leaflets.  6.  Lymphatic  trunks  which  arise  from  the  posterior  portion 
of  the  right  leaflet  and  right  pillar  of  the  diaphragm  ;  these  trunks,  three  or  four  in  number, 
terminate  in  the  prae-aortic  glands.  7,  7.  Lymphatic  trunks  which  come  from  the  pos- 
terior portion  of  the  left  leaflet  and  left  pillar  ;  they  pass  to  the  same  glands  as  the  pre- 
ceding. 8,  8,  8.  Lymphatic  networks  with  close  and  superposed  meshes,  which  cover  the 
fleshy  portion  of  the  diaphragm.  9,  9,  9,  9,  9,  9,  9.  Lymphatic  trunks  which  arise  from 
a  network  on  the  convex  part  of  the  fleshy  portion  of  the  muscle,  and  which  then  pass 
towards  the  lower  intercostal  spaces  and  end  in  the  aortic  glands.  10,  10,  10,  10.  Other 
smaller  networks  which  run  parallel  to  the  muscles  which  they  surround  ;  all  of  them  con- 
verge, some  running  from  without  inwards,  others  from  within  outwards,  and  terminate 
in  a  small  trunk  which  ends  in  the  plexus  of  collecting  trunks.  11,  11,  11,  11.  Plexus  of 
collecting  trunks  which  extends  from  behind  forwards  and  terminates  in  a  large  gland 
situated  on  the  cartilages  of  the  sixth  and  seventh  ribs.  12.  Gland  in  which  the  plexus 
of  the  collecting  trunks  terminates  :  this  gland  is  single  on  the  right  and  double  on  the 
left  side.  13.  Three  small  glands,  situated  in  front  of  the  pericardium,  and  to  some  extent 
hidden  in  the  surrounding  fat  ;  they  receive  some  lj  mphatic  trunks  which  traverse  first, 
the  suspensory  ligament  of  the  liver,  and  then  the  fleshy  portion  of  the  diaphragm.  From 
these  glands  run  several  trunks  which  pass  into  the  glands  on  the  right  and  left  of  the  xiphoid 
cartilage,  over  the  course  of  the  internal  mammary  vessels.  14,  14.  Glands  in  which  tho 
preceding  vessels  ternrnate,  and  which  are  continuous  with  the  plexus  of  the  collecting 
trunks. 


LYMPHATICS    OF    THE    THORAX  227 

arteries  and  which  come  from  the  muscles  attached  to  the  external 
surface  of  the  thorax  ;  but  as  we  have  seen,  these  muscles  send  the 
majority  of  their  lymphatics  into  the  axillary  glands. 

The  internal  and  external  intercostal  lymphatics  anastomose 
with  one  another.  Now,  if  we  admit  the  relations  which  the  first 
group  bears  to  the  lymphatic  network  of  the  pleura,  and  the  second 
to  the  lymphatic  tributaries  of  the  glands  of  the  axilla,  it  is  conceiv- 
able that  a  lesion  of  the  pleura  may  make  itself  felt  in  the  latter. 

Vide  SOULIGOUX.     Pathogenic  des  abces  froids  du  thorax.    Th.  Paris,  1894. 

LYMPHATICS  OF  THE  DIAPHRAGM. — The  lymphatics  of  the  dia- 
phragm arise  from  a  network  of  capillaries,  within  the  interstices 
of  the  muscular  fasciculi  of  the  fleshy  or  tendinous  fibres  of  the 
central  portion  of  the  diaphragm.  From  this  network  of  origin  run 
numerous  small  trunks,  some  of  which  descend  and  are  carried 
towards  the  concave  surface  of  the  diaphragm,  while  others-  ascend 
and  reach  its  convex  surface.  The  descending  trunklets,  which  are 
always  very  fine,  constitute  a  somewhat  scanty  network  beneath 
the  peritoneum  which  it  is  difficult  to  inject,  and  which  gives  origin 
to  trunks  which  ascend  towards  the  convex  surface.  The  ascending 
Intnklets,  which  are  much  more  important,  come  to  the  superior 
surface  beneath  the  pleura,  and  arrange  themselves  in  the  fol- 
lowing way  (vide  Fig.  84) :  In  the  central  part  of  the  diaphragm, 
they  form  a  network  with  very  close  meshes,  which  is  most 
developed  on  the  lateral  leaflets.  In  the  fleshy  portion  the 
trunks  sent  out  from  the  network  of  origin  run  parallel  to  the 
muscular  fasciculi,  and  converge  like  the  feathers  of  a  quill  towards 
the  middle  portion  of  the  fleshy  part.  Here  they  empty  themselves 
into  the  most  important  of  the  groups  of  collectors  which  we  are 
now  about  to  describe,  viz.  the  anterior  group. 

The  collecting  trunks  which  carry  on  the  lymphatic  circulation 
of  the  diaphragm  are  all  situated  upon  the  convex  surface  of  the 
latter.  We  may  with  Sappey  divide  them  into  three  groups,  viz. 
anterior,  middle  and  posterior. 

1.  The  anterior  collecting  trunks  appear  at  the  extremity  of  the 
lateral  leaflets.  They  vary  in  number  from  3  to  G.  Anastomosing 
with  each  other,  they  form  a  kind  of  plexus  with  coarse  meshes,  the 
plexus  of  the  collecting  trunks  (Sappey).  These  trunks  run  forwards, 
crossing  the  fleshy  fibres  in  their  central  portion.  In  their  course, 
they  collect  together  all  the  interfascicular  little  trunks  which 
implant  themselves  perpendicularly  upon  them.  They  thus  come 


228  SPECIAL    STUDY    OF    THE    LYMPHATICS 

to  the  anterior  portion  of  the  diaphragm  and  terminate  in  one  or 
two  glands  placed  opposite  the  outer  end  of  the  seventh  costal 
cartilage.  We  have  described  these  glands  as  the  lateral  glands  of 
the  anterior  diaphragmatic  group.  In  this  connexion  we  should 
remember  that  the  median  glands  of  the  same  group  receive  no 
afferents  from  the  diaphragm. 

2.  The  posterior  collecting  trunks  arise   from   a   network   which 
hides  the  lateral  leaflets.     From  4  to  6  in  number  on  either  side, 
they  run  downwards,  backwards  and  inwards  and  terminate  in  the 
glands  surrounding  the  aorta  just  as  this  vessel  is  leaving  the  thorax 
to  enter  the  abdomen. 

3.  The  middle  collecting  trunks,  which  spring  from  the  middle 
part  of  the  central  part  of  the  diaphragm,  have  a  threefold  ter- 
mination.    Some  pass  into  the  peri-oesophageal  glands  ;     others 
into  the  glands  which  surround  the  inferior  vena  cava  ;    others, 
finally,  end  in  the  glands  situated  to  the  left  of  the  pericardium. 
This  inconstant  group  of  glands  is  not  represented  in  Fi  v.  84. 

The  lymphatics  of  the  diaphragm  anastomose  with  those  of  the 
peritoneum  and  with  those  of  the  pleura.  The  discussions  raised  as 
to  the  existence  of  communications  between  the  lymphatics  of  the 
diaphragm  and  the  peritoneal  cavity  are  well  known.  We  will  not 
here  dwell  on  this  point  which  has  been  fully  treated  elsewhere  (vide 
General  Considerations,  p.  75,  and  Peritoneum,  vol.  iv.  p.  1062  1). 

§  2.  VISCERAL  LYMPHATIC  VESSELS. 

LYMPHATICS  OF  THE  HEART. — The  heart  is  the  only  part  of  the 
circulatory  apparatus  which  contains  lymphatic  vessels.  As  we 
have  seen  when  studying  the  structure  of  the  heart  (vide  p.  603 1), 
the  lymphatics  of  this  organ  belong  exclusively  to  the  myocar- 
dium. They  are,  moreover,  placed  at  the  peripheral  part  of  the 
cardiac  muscle,  and  are  not  to  be  found  in  its  substance.  They 
thus  constitute  two  networks,  one,  deep  and  sub-endocardiac,  and 
the  other,  superficial  and  sub-pericardiac. 

It  has  never  been  found  possible  to  inject  the  deep  network,  in 
man ;  its  collecting  trunks  empty  themselves  into  those  of  the  super- 
ficial network,  the  meshes  of  which  cover  the  whole  of  the  external 
surface  of  the  heart  ;  but  it  is  much  more  developed  on  the  ven- 
tricles than  on  the  auricles.  On  the  latter,  Sappey  was  unable  to 
demonstrate  the  superficial  network  except  in  the  case  of  the  ox 
and  horse. 

1  Treatise  of    Human  Anatomy.     Poirier  and  Charpy. 


LYMPHATICS    OF    THE    THORAX  229 

The  collecting  trunks  of  the  sub-pericardiac  network  have  an 
arrangement  which,  in  the  main,  is  similar  to  that  of  the  coronary 
arteries.  Thus  we  may  divide  them  into  the  left  or  anterior 
and  the  right  or  posterior. 

1.  The  left  or  anterior  collecting  trunks,  which  at  first  number  two 
or  more  rarely  three,  appear  on  the  anterior  surface  of  the  heart 
near  its  apex.     They  ascend,  running  parallel  to  the  anterior  inter- 
ventricular  furrow  and,  having  arrived  at  the  auriculo-ventricular 
groove,  unite  to  form  a  single  trunk  which  runs  between  the  left 
auricle  and  the  pulmonary  artery.     This  trunk  then  passes  on  to 
the  posterior  surface  of  this  large  vessel,  perforates  the  fibrous  layer 
of  the  pericardium  and  terminates  in  one  of  the  glands  of  the  inter- 
tracheo-bronchial  group. 

In  their  inter  ventricular  course,  these  left  or  anterior  coronary 
collectors  receive  several  branches  coming  from  the  anterior  surface 
of  the  two  ventricles.  In  the  inter  ventricular  furrow,  they  receive 
a  large  affluent,  viz.  the  left  auriculo- ventricular  collector.  This  is 
of  much  more  importance  than  the  corresponding  artery,  and  takes 
origin  from  the  diaphragmatic  surface  of  the  heart,  near  the  apex, 
enters  the  inferior  inter- ventricular  furrow,  then  turns  round  the 
left  half  of  the  auriculo-ventricular  groove,  and  finally  joins  the 
anterior  collectors.  It  drains  the  sub-pericardiac  network  of  the 
inferior  left  surface  of  the  left  ventricle,  and  the  corresponding 
network  of  the  left  auricle. 

2.  The  right  or  posterior  collecting  trunk  appears  on  the  diaphragm- 
atic surface  near  the  apex  ;    it  then  runs  along  the  inferior  inter- 
ventricular  groove,  then  along  the  right  portion  of  the  auriculo- 
ventricular  groove  and  thus  comes  to  the  anterior  surface  of  the 
heart.     It  then  ascends  between  the  pulmonary  artery  and   the 
aorta,  and  terminates,  like  the  common  trunk  of  the  left  collectors, 
in    one    of   the    intertracheo-bronchial    glands.      It    receives    the 
lymphatics  of   the  right  auricle,  and   posterior  surface   and  right 
border  of  the  right  ventricle.     We  have  seen  that  the  anterior  por- 
tion of  the  sub-pericardiac  network  of  the  right  ventricle  was  a 
tributary  of  the  left  or  anterior  collecting  trunks. 

LYMPHATICS  or  THE  LUNG. — The  origin  of  the  lymphatics  of  the 
lung  will  be  studied  further  on  together  with  the  structure  of  that 
organ  (vide  vol.  iv.  p.  529 1).  Here  we  need  only  remember  that 
these  vessels  arise  :  (1)  from  perilobular  networks,  which  in  certain 
•animals  such  as  the  ox  are  arranged  in  the  form  of  sacs  which  are 
1  Treatise  of  Human  Anatomy.  Poirier  and  Charpy. 


230  SPECIAL    STUDY    OF    THE    LYMPHATICS 

more  or  less  divided  off ;  (2)  from  networks,  which  are  attached  to 
the  bronchial  divisions  ;  these  networks  are  two  in  number  (one 
submucous,  the  other  peribronchial)  in  the  large,  but  are  a  single 
in  the  small  bronchi.  According  to  Miller,  this  network  extends 
to  the  alveolar  passages. 

From  these  networks  of  origin  run  two  kinds  of  collectors,  which 
after  Cruikshank  and  Mascagni,  we  may  divide  into  superficial  and 
deep,  this  classification  being  based  on  the  course  they  pursue  to 
reach  the  hilum  of  the  lung. 

1.  THE  SUPERFICIAL  COLLECTING  TRUNKS  arise  from  the  sub-pleural 
lobules.     At  their  origin  they  take  the  form  of  a  plexus  of  which 
each  mesh  is  polygonal  in  shape,  and  corresponds  with  the  base  of  a 
sub-pleural  lobule.     Their  ultimate  course   varies   for  each  lobe. 
It  has  been  perfectly  described  by  Sappey,  whose  description  we  can 
only  summarize. 

In  the  upper  lobe,  they  arise  on  the  costal  surface  of  the  lobe  and 
divide  into  three  groups,  one  of  which  turns  round  the  posterior 
border  of  the  lung,  the  other  the  anterior  border,  while  the  third 
penetrates  into  the  interlobar  fissure  to  run  on  the  inferior  surface 
of  the  lobe  :  they  thus  reach  the  hilum  and  terminate  in  the  glands 
placed  there. 

On  the  lower  lobe,  the  superficial  trunks  are  also  divided  into  three 
groups.  The  superior  trunks  penetrate  into  the  interlobular  fissure  ; 
the  posterior  and  anterior  trunks  turn  round  the  corresponding 
border  of  the  lung  and  reach  the  internal  surface  on  which  they 
mount  obliquely  towards  the  hilum. 

The  trunks  which  spring  from  the  middle  lobe  of  the  right  lung  are 
much  less  important  than  those  of  the  superior  and  inferior  lobes. 
Some  unite  with  the  trunks  of  the  superior,  others  with  the  collecting 
trunks  of  the  inferior  lobe  which  run  in  the  fissures. 

2.  THE  DEEP  COLLECTING  TRUNKS  run,  some  by  the  side  of  the 
bronchial  ramifications,  others  along   branches  of  the  pulmonary 
artery,  or   the  pulmonary  veins  (Miller).      All   run    towards    the 
hilum,  where  they  terminate  in  the  tracheo-bronchial  glands,  for 
the  description  of  which  we  must  refer  the  reader  to  the  preceding 
paragraph. 

It  is  generally  admitted  that  the  superficial  communicate  largely 
with  the  deep  collectors,  and  that  on  puncturing  the  former  the 
latter  are  readily  injected.  According  to  Miller,  anastomoses 
between  these  two  systems  of  collecting  trunks  are,  on  the  contrary, 
very  rare ;  this  author  maintains  that  when  after  injecting  the  super- 


LYMPHATICS    OF  THE   THORAX  231 

ficial  vessels,  the  deep  vessels  become  filled,  the  passage  of  the 
injected  material  from  the  former  into  the  latter  is  the  consequence 
of  the  blending  of  these  two  systems  of  vessels  at  their  termination 
in  the  glands  of  the  hilum. 

Lymphatics  of  the  Pleura. — As  we  shall  see  later  on,  the  exist- 
ence of  pleural  lymphatics  is  now  a  well  established  fact.  The 
lymphatics  of  the  visceral  layer  empty  themselves  into  the  super- 
ficial collecting  trunks  of  the  lung.  The  lymphatics  of  the  parietal 
layer  terminate  in  the  intercostal  trunks  for  the  costal  pleura,  in 
the  diaphragmatic  trunks  for  the  diaphragmatic  visceral  pleura,  in 
the  glands  of  the  posterior  mediastinum  for  the  mediastinal  pleura. 
When  adhesions  exist  between  the  two  layers,  the  lymphatics  of 
the  visceral  pleura  may,  by  means  of  newly-formed  lymphatics  con- 
tained in  these  adhesions,  communicate  with  the  lymphatics  of  the 
thoracic  wall. 

TECHNIQUE. — The  injection  of  the  superficial  lymphatics  is  fairly  easy, 
whether  mercury  or  Gerota' s  method  is  employed.  It  is  facilitated  b}'  moder- 
ately insufflating  the  lungs  and  by  the  previous  injection  of  the  blood  vessels. 

Miller  recommends  the  following  process  for  injecting  the  deep  lymphatics. 
A  dog  is  fed  for  several  days  on  a  diet  containing  a  great  quantity  of  fat. 
It  is  then  killed  by  chloroform.  The  heart  and  lungs  are  removed  en  masse, 
and  the  latter  are  moderately  insufflated.  One  of  the  subpleural  trunks  near 
the  hilum  is  then  sought  for,  which  with  a  little  practice  can  be  found 
without  much  difficulty.  A  direct  puncture  is  then  made  into  it  with  a  fine 
canula,  and  a  saturated  aqueous  solution  of  soluble  Prussian  blue  is  injected  ; 
the  mass  passes  as  far  as  the  glands,  then  flows  back  into  the  deep  lymphatics. 
In  spite  of  the  presence  of  valves  we  may  obtain,  an  almost  complete  injec- 
tion of  these  vessels  provided  we  employ  a  low  pressure,  and  make  the  in- 
jection very  slowly.  For  this  purpose  it  will  be  useful  to  have  an  apparatus 
in  which  a  continuous  pressure  can  be  maintained.  The  pressure  employed 
should  vary  between  10  and  15  mm.  of  mercury. 

HISTORICAL. — The  lymphatics  of  the  lungs  have  been  made  the  subject 
of  many  works.  They  were  noticed  for  the  first  time  by  Rudbeck  (1654). 
\Villis  gave  a  detailed  description  of  them  some  time  afterwards  ;  he 
described  them  in  the  dog,  and  demonstrated  them  by  tying  the  thoracic 
duct  at  its  termination  (1675)  :  but  we  must  turn  to  Cruikshank  and  Mas- 
cagni  to  find  a  sufficiently  exact  description  of  these  vessels  in  man  (1780). 
Since  then,  Sappey  has  undertaken  the  study  of  the  pulmonary  lymphatics 
and  definitely  established  their  macroscopic  arrangement.  Latterly,  the 
study  of  these  vessels  has  been  undertaken  from  the  microscopic  point  of 
view.  Grancher,  Renaut  and  Pierret,  Wywoclzoff ,  Sikorsky,  Klein,  v.  Wittich, 
and  Hoffmann  have  studied  the  lymphatics  of  the  lung  and  pleura  from  the 
histological  point  of  view.  We  shall  here  confine  ourselves  to  merely 
describing  the  gross  anatomical  appearances,  and  for  the  histological  works 
would  refer  the  reader  to  the  bibliographical  index  of  the  article  Lung 
(vide  vol.  iv.  p.  546  l),  and  to  a  recent  work  by  Miller  in  which  the  more  im- 
portant of  these  works  are  summarized. 

1  Treatise  of  Human  Anatomy,     Poirier  and  Charpy. 


232  SPECIAL    STUDY    OF    THE    LYMPHATICS 

MASCAGXI,  loc.  cit.,  p.  53  et  tab.  XX. — SAPPEY,  loc.  cit.,  p.  113  et  pi.  XLII 
Fig.  1,  2,  3,  4. — MILLER,  Das  Lungenlappchen,  seine  Blut-u.  Lymphgefasse. 
Arch.  f.'Anat.  u.  Phys.,  Aiiat.,  1900,  p.  197. 

LYMPHATICS  OF  THE  THORACIC  PORTION  OF  THE  TRACHEA. — 
The  lymphatics  of  the  thoracic  portion  of  the  trachea  arise  from 
a  sub-mucous  network,  which  is  richer  than  the  corresponding 
network  of  the  cervical  portion  of  this  organ.  From  this  network 
run  many  trunks  which  perforate  the  wall  of  the  trachea  at  the 
junction  of  its  cartilaginous  and  membranous  portions,  and  ter- 
minate in  the  right  and  left  peritracheo-bronchial  and  intertracheo- 
bronchial  glands. 

LYMPHATICS  OF  THE  THORACIC  PORTION  OF  THE  OESOPHAGUS.— 
The  lymphatics  of  the  intra-thoracic  portion  of  the  oesophagus 
arise  from  two  networks,  one  sub-mucous,  and  the  other  intra- 
muscular. From  this  network  several  collectors  arise  which  empty 
themselves  into  the  peri-oesophageal  glands  which  we  have  de- 
scribed above  (vide  p.  215). 

LYMPHATICS  OF  THE  THYMUS. — The  origin  of  the  lymphatics 
of  the  thymus  will  be  studied  together  with  the  structure  of  that 
organ  (vide  vol.  iv.  p.  565 1).  We  need  now  only  call  to  mind  the 
fact  that  these  lymphatics  arise  within  the  lobules  of  the  thymus 
from  the  peri-  and  interfollicular  sinuses.  They  terminate  in  col- 
lecting trunks,  which  run  in  the  interfollicular  septa.  Our  know- 
ledge of  the  terminal  glands  of  the  trunks  which  carry  on  the  lym- 
phatic circulation  of  the  thymus  is  still  imperfect.  It  is  generally 
admitted,  however,  that  these  vessels  end  in  the  supra-aortic  and 
praetracheo-bronchial  glands  and  in  the  glands  of  the  internal 
mammary  chain. 

1  Treatise  of  Human  Anatomy.     Poirier  and  Charpy. 


CHAPTER  IV 

LYMPHATICS    OF    THE    UPPER    LIMB 

LIKE  the  lymphatics  of  the  lower  limb,  the  absorbent  vessels  of 
the  upper  limb  may  be  divided  into  two  groups.  One,  the 
superficial  lymphatics,  run  in  the  subcutaneous  cellular  tissue. 
The  other,  the  deep  lymphatics,  run  under  the  deep  fascia, 
and  are  satellites  of  the  vessels  and  nerves.  All  finally  converge 
towards  the  glands  of  the  axilla,  after  presenting  in  their  course 
glands  which  are  very  variable  both  in  number  and  arrangement. 
We  will  first  indicate  the  arrangement  of  the  glands  in  con- 
nexion with  the  lymphatic  vessels  of  the  upper  limb,  and  then 
study  these  vessels  themselves. 

§1.     LYMPHATIC  GLANDS  OF  THE  UPPER  LIMB. 

The  glands  connected  with  the  lymphatic  apparatus  of  the  upper 
limb  are  situated  principally  in  the  axillary  cavity  at  the  root  of 
the  limb.  These  axillary  glands  form  the  common  meeting-place 
of  all  the  superficial  and  deep  lymphatics  of  the  upper  limb,  in  the 
same  way  as  the  inguinal  glands,  their  homologues  of  the  lower 
limb,  carry  on  all  the  lymphatic  circulation  of  the  latter. 

But,  in  addition  to  these  axillary  glands,  we  meet  with  isolated 
or  agminated  glands  scattered  in  small  groups  throughout  the 
whole  extent  of  the  upper  limb,  whose  signification  is  absolutely 
different.  We  must  regard  them  as  simple  interrupting  glandular 
nodules  placed  in  the  course  of  the  different  collecting  trunks. 
It  is  important,  however,  to  notice  that  some  of  these  glands  tend 
to  acquire,  by  their  frequency,  size,  and  relatively  constant  position, 
the  significance  of  regional  glands.  We  here  again  find,  as  in 
other  parts  of  the  system,  this  tendency  of  central  glands  to  extend 
towards  the  periphery,  but  it  would  seem  that  in  the  case  of  the 
upper  limb  this  evolution  is  less  advanced  than  in  the  case  of  the 
lower  limb: 

These  interrupting  glandular  nodules,  or,  if  we  prefer  to  call 
them  so,  these  aberrant  glands,  are  placed,  some  in  the  subcutaneous 


234  SPECIAL    STUDY    OF    THE    LYMPHATICS 

cellular   tissue    (superficial  glands),    others   under   the    deep   fascia 
(deep  glands). 

1.  SUPERFICIAL  GLANDS. — The  superficial  glands  have  two 
seats  of  election,  viz.  the  supra-epitrochlear  region  and  the  groove 
between  the  deltoid  and  pectoralis  major. 

(a)  The  supra-epitrochlear  gland  is  usually  single,   but  we  may 
meet  with  two  or  even  three  in  this  situation.     The  supra-epitroch- 
lear gland  is  usually  placed  three  or  four  centimetres  above  the 
epitrochlea.     It   lies   immediately   upon   the   deep    fascia,    and   is 
therefore    covered    by   the   whole   thickness    of   the    subcutaneous 
adipose   tissue.     Thus,    unless   this   gland   is   hyper trophied,    it   is 
difficult  to  detect  it  by  palpation. 

The  supra-epitrochlear  gland  receives  as  afferent  vessels,  some 
of  the  superficial  collectors  which  run  along  the  ulnar  border  of 
the  forearm,  and  which  drain  the  three  inner  fingers  and  inner 
portion  of  the  hand.  But  we  must  observe  that,  on  account  of 
the  many  anastomoses  by  which  the  different  antibrachial  collect- 
ing trunks  are  united,  this  gland  may  be  affected  by  lesions  situated 
at  the  external  part  of  the  forearm  and  hand. 

The  efferent  vessels  of  this  gland  at  first  accompany  the  basilic 
vein,  beneath  which  they  run.  In  the  middle  part  of  the  arm 
they  pierce  the  deep  fascia,  together  with  the  vein,  and  unite  with 
the  deep  lymphatics,  the  satellites  of  the  brachial  vessels. 

(b)  hi  the  groove  between  the  deltoid  and  the  pectoral  we  may  meet 
with  one,  two,  and  sometimes  three  glands.     These,  which  were 
pointed  out  by  Aubry,  are  always  very  small.     They  are  simple 
interrupting  nodules  placed  in  the  course  of  the  interde It o  -pectoral 
collecting  trunk,  which  we  shall  describe  further  on.     According 
to  Grossmann,  these  glands  are  present  in  14  out  of  every  100  cases. 

2.  DEEP  GLANDS. — Some  small  glands  may  be  met  with  in 
the  course  of  the  deep  lymphatics.  They  have  been  noticed  along 
the  radial,  ulnar  and  interosseous  arteries,  but  the  only  ones  which 
appear  with  any  constancy  are  those  which  are  met  with  in  the 
course  of  the  brachial  artery,  where  there  are  two  to  three  small 
glands  usually  placed  in  the  centre  of  the  arm. 

These  deep  glands  were  a  long  time  ago  figured  by  Mascagni  (loc.  cit., 
plate  xxv.,  Figs.  2  and  3)  and  have  since  been  described  and  figured  by 
Meckel,  Michel,  Dubois  (Soc.  Anat.,  1850),  Bourgery  (loc.  cit.,  plate  64, 
Fig.  1),  Leaf  (loc.  cit.,  p.  45,  Fig.  10). 

AXILLARY  GLANDS.— The  axillary  glands  constitute  a  very  im- 
portant glandular  centre,  for  they  receive  not  only  the  whole  of 


LYMPHATICS    OF    THE    UPPER    LIMB 


235 


the  absorbent  vessels  of  the  upper  limb,  but  also  the  lymphatics 
from  the  skin  of  all  the  upper  part  of  the  trunk,  as  well  as  those 
from  the  subjacent  muscles. 

The  number  of  axillary  glands  varies  from  twelve  to  thirty -six. 
According  to  Grossmann,  there  are  usually  more  on  the  right  than 
on  the  left  side  (?). 


FIG.  So. — Lymphatics  of  the  breast  and  axillary  glands  (semi-diagrammatic). 

1.  Pel  to -pectoral  gland.  2,  2.  Glands  of  the  humeral  chain.  3,  3,  Glands  of  the  central 
group  and  tho  scapular  chain.  4,  4.  Glands  of  the  thoracic  chain  (supero-internal  group). 
5.  Gland  of  the  thoracic  chain  (infero-external  group).  ti.  Subclavian  glands.  7.  Mam- 
mary lymphatic  ending  in  the  subclavian  glands  (inconstant).  8,  9.  Mammary  collecting 
trunks,  ending  in  glands  of  the  thoracic  chain.  10.  Sub-areolar  plexus.  11.  Cutaneous 
collecting  trunk  of  the  lateral  walls  of  the  thorax.  12,  13.  Mammary  collecting  trunks 
about  to  end  in  the  internal  mammary  glands. 

The  topography  of  the  axillary  glands  has  given  rise  to  numerous 
discussions,  and  has  originated  a  large  number  of  works,  amongst 
which  we  may  mention  those  of  Kirmisson,  Poirier,  Leaf,  Oelsner, 
etc.  We  have  recently  studied  these  glands  in  some  twenty  speci- 
mens, after  injecting  their  principal  afferents  by  Gerota's  method. 

The  general  arrangement  of  axillary  glands  may  be  summarized 
as  follows  :  the  majority  of  these  glands  are  sub-fascia! ;  they 
are  arranged  in  several  chains,  are  attached  to  the  different  walls 


236  SPECIAL  STUDY    OF    THE   LYMPHATICS 

of  the  axillary  cavity,  towards  the  summit  of  which  they  con- 
verge. The  description  of  the  relations  between  the  axillary  glands 
and  the  different  layers  of  fascia  varies  according  to  the  view  we 
take  of  the  arrangement  of  these  fasciae.  Denying  the  existence 
of  a  fascia1  which  closed  in  the  lower  part  of  the  axillary  cavity, 
one  of  the  present  writers  admitted  that  some  of  the  axillary  glands 
were  subcutaneous.  Later  researches  have  partially  modified 
this  view.  With  Langer.  we  admit  the  presence  in  the  axilla  of  a 
fascia,  which  has,  it  is  true,  in  its  centre  a  large  orifice  bounded 
by  the  "  armbogen  "  and  the  "  achselbogen  "  (vide2  vol.  ii.  part  i., 
p.  164,  and  Figs.  126,  127,  and  128).  This  being  so,  it  is  indis- 
putable that  the  axillary  glands  are  covered  by  this  fascia  ;  but 
even  though  some  of  them  protrude  through  the  central  orifice, 
we  should,  not  for  all  that  regard  them  as  subcutaneous.  On  the 
other  hand,  it  would  be  going  too  far  to  deny  the  possible  existence 
of  subcutaneous  glands. 

The  "  armbogen  "  is  the  inferior  and  outer,  the  ';  achselbogen  "  the 
superior  and  inner  margins  of  an  opening  in  the  axillary  fascia  described 
by  Langer  (Zur  Anat.  der  Muse  latissimus  dors.  Oester.  Med.  Woch., 
1846,  Nos.  15  and  16),  and  by  Poirier  (Progres  Medical,  1888,  pp.  68-71). 

The  axillary  glands  are  embedded  in  the  cellulo-adipose  tissue 
which  fills  in  the  axilla.  We  may  classify  them  as  follows  :  At 
the  base  of  the  armpit  they  form  three  distinct  chains.  One  of 
these  chains  (the  humeral  chain)  is  attached  to  the  external  wall 
of  the  axilla,  and  follows  the  principal  vessels  and  nerves.  A 
second  chain  (the  thoracic  chain)  accompanies  the  external  mammary 
artery  as  it  runs  on  the  internal  wall.  A  third  chain  (the  scapular 
chain),  a  satellite  of  the  subscapular  artery,  is  attached  to  the 
posterior  wall  of  the  axilla.  Between  these  three  chains  a  group 
of  glands  is  found  which,  with  Grossmann  and  Oelsner,  we  will 
term  the  central  group.  The  scapular  chain  empties  itself  into 
the  humeral  chain,  and  the  latter  blends  with  the  thoracic  chain 
to  form  the  sub-clavicular  group,  which  occupies  the  summit  of 
the  axillary  pyramid  (vide  Figs.  85  and  86). 

1.  The  humeral  chain  comprises  four  to  five  glands,  which  are 
attached  to  the  inner  surface  of  the  principal  vessels  and  nerves. 
These  glands  are  more  particularly  in  relation  with  the  axillary 

1 1  denied  the  presence  of  the  fascia  at  the  base  of  the  armpit,  as  it  was 
then  described,  because  the  armpit  which  is  a  hollow  pyramid,  has  no  base. 
There  as  everywhere,  the  fasciae  follow  the  muscular  planes,  and  when  a 
bundle  of  vessels  and  nerves  is  met  with  they  divide  and  enclose  them  in  a 
sheath  :  in  this  respect  the  axilla  does  not  differ  from  the  inguinal  region. 
2  Treatise  of  Human  Anatomy.  Poirier  and  Charpy. 


LYMPHATICS    OF    THE    UPPER    LIMB  237 

vein,  behind  which  some  of  them  sometimes  insinuate  themselves, 
and  become  inserted  between  this  vessel  and  the  subscapularis. 

2.  The  thoracic  chain  is  usually  formed  by  two  distinct   masses. 
From  their  relative  situation,  we  may  divide  them  into  supero- 
intemal    and    supero-external.     The    supero-internal    mass    com- 
prises two  to  three  glands  placed  in  the  second  or  third  intercostal 
space,  in  front  of  the  trunk  of  the  external  mammary  artery.    These 
glands  are  hidden  by  the  lower  border  of  the  pectoralis  major  if 
this  muscle  is  well  developed,  but  lie  beneath  its  lower  border  in 
poorly  developed  subjects.     This  glandular  mass  corresponds  to 
the   superficial  thoracic  glands  of   Grossmann,   and  to  the  anterior 
thoracic  lymph  glands  of  Oelsner.     It  is  also  sometimes  called  the 
group  of  Sorgius.     The  in fero- external  mass  comprises  2  to  3  glands 
placed  behind  or  in  the  course  of  the  external  mammary  vessels 
in  the  fourth  and  fifth  intercostal  spaces  (the  deep  thoracic  glands, 
Grossmann  ;     the  inferior   thoracic   lymph  glands,    Oelsner). 

3.  The  scapular  chain  comprises  6  to  7  glands,  which  are  ranged 
one  above  the  other  along  the  dorsalis  scapulae  artery,  in  the  groove 
which  separates  the  teres  major  from  the  subscapularis.      In  this 
chain  we  may  include  2  or  3  little  glands  which  are  almost  con- 
stantly found  on  the  dorsal  surface  of  the  scapula  near  its  inferior 
angle  in  the  groove  which  separates  the  teres  major  from  the  teres 
minor  (Oelsner). 

4.  The   central  group  (intermediate   glands,  Grossmann,  Oelsner) 
comprises   3  to  5  glands,  placed  between  the  preceding  chains,  to 
which  they  are  united  by  several  anastomoses.     These  glands  are 
embedded  in  the  cellule-adipose  tissue  near  the  base  of  the  axilla, 
and  sometimes  protrude  through  the  foramen  of  Langer  (orifice 
in  axillary  fascia). 

5.  The  subscapular  group  comprises  (3  to  12  glands  placed  above 
the  upper  border  of  the  pectoralis  minor.     The  majority  of  these 
glands   are   situated  internal   to   the   axillary   vein,   between   this 
vessel  and  the  first  digitation  of  the  serratus  magnus.     We  almost 
always  find  one  of  these  glands  lying  in  front  of  the  vein,  at  the 
spot  where  it  is  joined  by  the  cephalic  ;    it  is  more  rare  to  find 
them  placed  external  to  the  vessels,  in  front  of  the  roots  of  the 
brachial  plexus. 

The  subclavian  group  is  continuous  below  without  any  clear  line  of 
demarcation  with  the  other  groups  of  the  axilla,  and  we  cannot  too  forcibly 
insist  on  the  extremely  arbitrary  character  of  this  subdivison  of  the  axillary 
glands  into  several  groups.  The  group  which  we  have  just  described  under 
the  name  of  sub-clavicular  glands,  contains  according  to  Grossmann,  two 


238  SPECIAL    STUDY    OF    THE    LYMPHATICS 

secondary  masses,  viz.  the  infra-clavicular  and  the  subpectoral  glands. 
It  does  not  appear  to  us  that  this  distinction  made  by  Grossmann  (whose 
description  moreover  is  most  obscure)  can  be  justified  by  the  arrangement 
of  the  glands  in  question. 

AFFERENT  VESSELS. — Each  glandular  group  of  the  axilla  re- 
ceives different  afferents. 

In  the  humeral  glands  terminate  almost  all  the  superficial  and 
deep  lymphatics  of  the  upper  limb.  We  have  seen,  in  fact,  that 
it  is  only  the  most  external  of  the  collecting  trunks  of  the  arm 
which  runs  up  in  the  delto-pectoral  groove  and  terminates  directly 
in  a  subclavian,  or  more  rarely  a  supraclavian  gland.  Again,  it 
is  important  to  observe  that,  according  to  Grossmann,  this  vessel 
only  exists  in  38  out  of  every  100  cases. 

The  thoracic  glands  receive  the  cutaneous  lymphatics  of  the 
anterior  and  lateral  parts  of  the  thorax,  the  lymphatics  of  the 
subjacent  muscles,  and  the  lymphatics  of  the  breast.  The 
anterior  cutaneous  and  the  mammary  lymphatics  more  particularly 
end  in  the  supero-internal  group  ;  the  absorbent  vessels  of  the 
lateral  wall  of  the  thorax  in  the  infero-external  group. 

The  glands  of  the  scapular  chain  receive  the  lymphatics  of  the 
integuments  of  the  lower  part  of  the  neck,  of  the  entire  dorsal  and 
posterior  surfaces  of  the  scapular  region.  They  also  receive  the 
absorbents  of  the  subjacent  muscles  (vide  Fig.  81). 

The  central  glands  do  not  really  receive  any  afferents  coming 
directly  from  lymphatic  territories,  which  are  tributaries  of  the 
axillary  glands.  On  the  contrary,  we  shall  presently  see  that  they 
form  the  terminus  for  the  majority  of  the  efferents  of  the  pre- 
ceding groups. 

The  same  remark  applies  to  the  subclavian  glands.  They  receive 
as  direct  afferents  hardly  any  but  the  satellite  trunk  of  the  cephalic 
vein  and  some  collectors  of  small  size  which  accompany  the  thoracic 
branch  of  the  acromio-thoracic  artery  and  which  come  from  the 
great  pectoral  and  possibly  from  the  mammary  gland  (Grossmann, 
Rotter,  vide  p.  222).  As  a  compensation,  however,  they  re- 
ceive almost  all  the  efferent  vessels  of  the  other  axillary  glands. 

This  description  of  the  afferent  vessels  of  the  different  glandular  groups 
is  necessarily  dogmatic.  It  is  not  rare  to  see  a  vessel,  no  matter  from  which 
of  the  lymphatic  territories  it  may  spring,  end  in  a  glandular  group  other  than 
that  which  represents  the  usual  terminus  of  the  collectors  of  the  territory  in 
question  ;  thus  Xagel  has  seen  one  of  the  trunks  coming  from  the  sub- 
areolar  plexus  send  a  branch  to  a  humeral  gland  before  terminating  in  the 
supero-internal  thoracic  glands.  Similarly,  Grossmann  and  Rieffel  have 
seen  a  mammary  collector  directly  reach  a  subclavian  gland.  We  may  also 


LYMPHATICS  OF  THE  UPPER  LIMB 


239 


see  a  humeral  or  scapular  collecting  trunk  terminate  in  a  gland  of  the 
thoracic  chain.  It  would  be  easy  to  multiply  examples.  It  is  none  the  less 
true  that  the  classification  we  have  given  of  the  afferents  of  the  axillary 
glands  applies  to  the  great  majority  of  cases  ;  and  with  the  reservation  that 
it  may  be  subject  to  a  certain  number  of  exceptions,  there  is,  in  our  opinion, 
an  advantage  in  retaining  it. 

EFFERENT  VESSELS. — The  efferent  vessels  of  the  axillary  glands 
are  somewhat  complex,  and  we  may  classify  them  as  follows  (vide 
Fig.  86)- 

The  efferents  of  the  humeral  group  have  a  threefold  termination  ; 
some  pass  into  the  central  group  ;  others  into  the  subclavian  glands  ; 
and  others  ascend  into  the  region  above  the  clavicle  and  terminate 
in  one  of  the  glands  situated  there.  This  latter  mode  of  termina- 
tion is,  according  to  Oelsner,  the  most  important  and  the'  most 
constant. 

Abnormally  we  may  see  one  of  the  efferent  vessels  of  a  gland  of  the  humeral 
group  perforate  the  anterior  wall  of  the  axilla  from  behind  forwards,  at  the 
apex  of  the  axilla,  then  cross  the  clavicle  and  end  in  a  supra-clavicular 
gland  (Grossmann). 

The  efferents  of  the  thoracic  chain  end  in  the  glands  of  the  central 
group.  Almost  always,  however, 
certain  efferents  which  come 
from  the  super o-internal  mass, 
directly  reach  the  subclavian 
glands  running  either  in  front  of 
or  behind  the  pectoralis  minor. 
In  the  latter  case  we  may  find 
little  glandular  nodules  lying  on 
the  course  of  these  vessels  (Gross- 
mann). The  efferents  of  the  glands 
of  the  scapular  chain  empty  them- 
selves into  the  humeral  and  cen- 
tral glands. 

These  central  glands  send  their 
efferents     into      the     subclavian 


FIG.  86. — Scheme  of  the  axillary  glands. 


a.  Supra-clavicular  glands.  6.  Subclavian 
glands,     c.  Humeral  chain.      d.  Scapular 
glands  ;    thus,  in  these   Subclavian      chain,     c.  Infero-extcrnal   portion    of    the 
,  ,,      ,,  rf  thoracic   chain.      /.  Supero-internal    por- 

glands  nearly  all  the  efferents 
of  the  four  glandular  groups  of 
the  axilla  finally  terminate. 

The  subclavian  glands  give  rise  to  numerous  efferents  which 
by  their  anastomoses  form  a  plexus  (infraclavicular  plexus).  They 
soon  resolve  themselves  into  a  single  trunk,  the  subclavian  trunk, 


tion  of  the  thoracic  chain,  g.  Central 
group.  The  dark  dotted  line  indicates 
the  situation  of  the  clavicle. 


240  SPECIAL    STUDY    OF    THE    LYMPHATICS 

which  runs  in  front  of  the  subclavian  vein,  between  the  latter  and 
the  subclavius  muscle,  and  terminates  at  the  summit  of  the  angle 
which  the  subclavian  vein  forms  by  its  junction  with  the  external 
jugular. 

The  arrangement  of  this  subclavian  trunk  which  carries  on  the  lymphatic 
circulation  of  the  upper  limb  is  subject  to  variation.  Most  usually,  this 
trunk  ends  by  itself  as  we  have  just  pointed  out,  in  the  junction  of  the  inter- 
nal jugular  and  subclavian  veins.  On  the  left,  it  may  terminate  in  the 
thoracic  duct  ;  Grossmann  has  met  with  this  arrangement  twice  in  twenty- 
five  subjects,  but  in  these  two  cases  the  subclavian  trunk  was  double,  and 
only  one  of  the  two  secondary  trunks  emptied  its  contents  into  the  thoracic 
duct.  It  is  still  more  rare  to  see  the  subclavian  trunk  unite  with  the  jugular 
trunk  before  ending  in  the  junction  of  internal  jugular  and  subclavian. 
Grossmann  has  only  met  with  this  arrangement  once  in  twenty-five  subjects, 
and  in  this  case,  too,  the  subclavian  trunk  was  double,  and  the  larger  of  the 
two  secondary  trunks  opened  directly  into  the  junction  of  the  internal 
jugular  and  subclavian.  The  existence  of  a  trunk  common  to  the  lymphatics 
of  the  right  upper  limb  and  corresponding  side  of  the  neck  is  therefore  an 
exceptional  arrangement,  and  the  right  lymphatic  duct  is  most  usually 
absent.  However,  we  shall  return  to  this  point  when  we  study  the  terminal 
collecting  trunks  of  the  lymphatic  system  (vide  p.  291). 

We  have  seen  that  the  subclavian  trunk  usually  ends  at  the  apex  of  the 
angle  formed  by  the  junction  of  the  subclavian  and  the  external  jugular 
veins.  According  to  Grossmann,  this  arrangement  is  met  with  in  40  out  of 
100  cases.  Fairly  frequently  (in  36  out  of  100  cases),  this  trunk  terminates 
on  the  anterior  wall  of  the  subclavian  vein.  In  10  out  of  100  cases,  it  ends 
in  the  upper  border  of  this  vessel,  about  a  centimetre  from  the  venous  angle. 
In  6  out  of  100  cases,  the  subclavian  trunk  ends  in  the  posterior  wall  of  the 
subclavian  vein. 

Nearly  always  one  or  more  of  the  efferents  of  the  subclavian  glands  pass 
into  one  of  the  glands  of  the  subclavian  triangle.  We  may  even  see  one  of 
these  vessels  reach  these  glands  by  passing  in  front  of  the  clavicle  (Gross- 
mann). 

Sur  les  ganglions  axillaires,  voy.  :  KIRMISSON,  Note  sur  la  topographic  des 
ganglions  axillaires.  Soc.  anat.,  1882,  p.  453. — POIRIER,  Notes  anatom.  sur 
1'aponevrose,  le  ligament  suspenseur  et  les  ganglions  lymphatiques  de 
1'aisselle.  Progres  medical,  1888,  p.  68. — GROSSMANN,  Ueber  die  axillaren 
Lymphdriisen.  Th.  Berlin,  1896. — LEAF,  loc.  cit.,  p.  39,  fig.  8  et  9. — (ELSNER, 
Anat.  Unters.  iiber  der  Lymphw.  der  Brust  mit  Bericht.,  etc.  Arch.  /.  klin. 
Chir.,  1901,  p.  135. 

§2.     LYMPHATIC  VESSELS    OF   THE   UPPER   LIMB. 

As  we  have  seen,  the  lymphatic  vessels  of  the  upper  limb  may 
be  divided  into  two  groups  :  the  superficial  lymphatics,  which  arise 
from  the  integuments,  and  whose  collecting  trunks  run  in  the  sub- 
cutaneous cellular  tissue  ;  and  the  deep  lymphatics,  which,  spring- 
ing from  the  sub-aponeurotic  structures,  end  in  the  satellite  trunks 
of  the  deep  blood  vessels. 


LYMPHATICS  OF  THE  UPPER  LIMB 


241 


SUPERFICIAL    LYMPHATICS. — The    superficial    lymphatics    come 
from  all  parts  of  the  cutaneous  covering  of  the  limb,  but  it  is  in 
the  fingers  and  the  palm  of  the  hand  that  the  network  of  origin 
is  the  richest.     It  is  therefore  at  these  points, 
and  more  particularly  on  the  palmar  surface 
of  the  fingers,  that  punctures  must  be  made 
for   the   injection    of    the    lymphatics   of   the 
upper  limb. 

The  collecting  trunks  of  the  superficial 
network  appear  at  the  roots  of  the  fingers 
and  at  the  base  of  the  palm  of  the  hand.  They 
then  run  upwards  on  the  forearm  and  arm,  re- 
ceiving as  they  ascend  the  lymph  from  other 
parts  of  the  cutaneous  covering.  They  ter- 
minate in  the  glands  of  the  axilla.  We  will 
study  first  their  digital  and  palmar  origin, 
and  then  their  course  and  termination. 

Origins  :  (A)  In  the,  fingers,  the  network 
of  origin  presents  its  maximum  of  develop- 
ment on  the  palmar  surface  (vide  Fig.  88). 
Here  the  meshes  are  so  closely  set,  that  it  is 
only  by  a  careful  examination  with  a  lens 
that  they  can  be  distinguished.  The  dorsal 
network  is  much  less  rich  than  the  preceding 
(vide  Fig.  89).  From  these  two  networks  arise 
a  considerable  number  of  collectors,  which 
converge  towards  the  sides  of  the  fingers  and 
unite  to  form  2  or  3  trunks  on  each  of  these 
surfaces.  These  trunks  at  first  follow  the 
corresponding  collateral  artery,  but,  having 
arrived  at  the  base  of  the  finger,  they  incline 
backward,  and  run  towards  the  interdigital  space.  They  then 
pass  to  the  posterior  surface  of  the  hand,  and  are  directed 
towards  the  wrist,  where  we  shall  trace  them  again  shortly. 
In  their  course  on  the  dorsal  surface  of  the  hand,  they  effect 
numerous  anastomoses.  They  cross  one  another  frequently, 
and  it  is  no  unusual  thing  to  see  a  collecting  trunk,  which 
has  arisen  for  example  in  the  fourth  interdigital  space,  uniting 
with  trunks  which  ran  along  the  external  part  of  the  dorsal  surface 
of  the  hand. 

(B)  In  the  palm  of  the  hand,  the  network  of  origin  is  also  ex- 


^ 

FIG.    87.  - 

network  of  the  pal- 
mar surface  of  the 
fingers  (after  Sappey). 

This  figure  shows  tho 
capillaries  which  form 
the  most  superficial  part 
of  the  lymphatic  net- 
work of  the  fingers. 


242 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


tremely  rich.  From  this  network  run  numerous  trunklets  which 
we  may  divide  into  external,  internal,  inferior,  superior  and  central 
(vide  Fig.  88). 

The  external  trunk- 
lets,  4  to  6  in  number, 
run  obliquely  upwards 
and  outwards,  and 
crossing  the  surface  of 
the  thenar  eminence  in 
a  slanting  direction, 
terminate  in  the  lym- 
phatics coming  from 
the  integuments  of  the 
thumb. 

The  internal  trunk- 
lets,  more  numerous 
than  the  preceding  (8 
or  10),  run  almost 
transversely  inwards, 
and  crossing  the  ulnar 
border  of  the  hand, 
reach  the  dorsal  sur- 
face, and  empty  them- 
selves into  the  collect- 
ing trunks  which  arise 
from  the  integuments 
of  the  little  finger. 

The  inferior  trunklets, 
which  vary  from  12 
to  15  in  number,  are 
directed  towards  the 
interdigital  spaces ;  the}' 
then  reach  the  dorsal 
surface  of  the  hand 
and  terminate  in  the 


FIG.  88.— The  lymphatics  of  the  palmar  surface  of 
the  hand  (after  Sappey). 

1,  1,  1.  Lymphatic  branchlets  of  the  palmar  surface 
of  the  fingers.  2,  2,  2.  Lymphatic  branchlets  of  the 
palm  of  the  hand.  3,  3.  Small  lymphatic  trunks  coming 
from  the  inferior  part  of  the  palmar  region  and  con- 
verging towards  the  interdigital  spaces  to  run  on  the 
dorsal  surface  of  the  metacarpus.  4,  4.  Little  trunks 
turning  round  the  hypothenar  eminence  to  terminate  in 
the  trunks  which  ramify  on  the  clor?al  surface  of  the  fifth 
metacarpal.  6.  Trunk  which  comes  from  the  central 
part  of  the  palm  of  the  hand  and  is  formed  by  six  to 
eight  trunklets.  6,  6.  Little  trunks  coming  from  the 
thenar  integuments.  7,  7,  7.  Trunks  in  which  they 
end.  8,  8.  Smaller  and  larger  trunks  which  arise  from 
the  anterior  part  of  the  wrist. 


digital 


collecting 


trunks. 

The    superior    trunk- 
lets  reach  the    anterior 

surface     of    the    wrist,   and  unite  to  form   3  or   4  trunks,  which 

ascend  on  the  anterior  surface  of  the  forearm. 


LYMPHATICS  OF  THE  UPPER  LIMB 


243 


The  central  trunklets  run  towards  the  deep  portion.  They  tra- 
verse the  subcutaneous  fatty  layer  and  the  superficial  palmar 
fascia,  and  then  usually  unite  into  a  single  trunk.  The  latter, 
which  has  been  well 
described  by  Sappey, 
takes  the  following 
course  :  It  is  directed 
immediately  out- 
wards, running  un- 
derneath the  fascia , 
in  front  of  the  flexor 
tendons.  It  thus 
comes  to  the  adduc- 
tor transversus  pol- 
licis,  crosses  the 
inferior  border  of 
this  muscle,  and  then 
crosses  the  outer 
border  of  the  first 
dorsal  inter-osseous, 
on  the  posterior  sur- 
face of  which  it 
ascends.  It  there 
joins  collectors  com- 
ing from  the  index 
finger  and  in  com- 
pany with  the  latter- 
reaches  the  dorsal 
surface  of  the  wrist. 

COURSE  :  All  these 
collecting  trunks, 
which  arise  from  the 
integuments  of  the 
fingers  and  hand, 
run  in  the  subcut- 
aneous cellular  tissue 
towards  the  root 

of  the  limb.  They  are  usually  more  superficial  than  the 
veins  whose  trunks  they  cover.  They  diminish  in  number  as 
they  are  traced  upward.  In  the  forearm  there  are  about  thirty 
but  in  the  middle  of  the  arm  not  more  than  15  to  18  (Sappey). 


MMMOfiUfa 

Lymphatic  vessels  of  the  dorsal  surface  of 

the  hand  (after  Sappey). 

1,  1,  1.  Lymphatic  branchlets  of  the  .mbungual  skin. 
2,  2.  Lymphatic  branchlets  arising  from  the  dorsal  surface 
of  the  fingers.  3.  Truiicules  which  run  from  tho  internal 
lateral  surface  of  the  thumb.  4,  4.  Trunk  formed  by  the 
union  of  these  truneules.  ft,  o.  Truiicules  which  come  from 
the  central  part  of  the  palm  of  the  hand,  and  which, 
somewhat  tardily,  unite  here  to  form  a  %ery  large  trunk. 
6,  0.  Lymphatic  trunks  coming  from  tlu1  fingers,  and 
from  the  inferior  part  of  the  palmar  region.  7,  7.  Col- 
lection of  trunks  which  run  on  the  dorsal  surface  of  the 
hand.  8,  8.  These  same  trunks  passing  from  the  haud 
over  the  forearm. 


244         SPECIAL    STUDY    OF    THE    LYMPHATICS 


10. 


12. 


I// 


In  the  wrist,  they  are  divided  into  two  groups,  of  which  one  runs 
on  the  dorsal,  the  other  on  the  palmar  surface  of  this  part  of  the 
limb. 

In  the  forearm,  they  tend  to  divide  themselves  into  three  groups, 
an  external  group,  which  ascends  along  the 
radial  border  of  the  forearm  ;  an  internal 
group,  which  follows  the  ulriar  border ;  a 
middle  group,  which  is  a  satellite  of  the 
median  vein  and  runs  between  the  two 
preceding. 

A  little  below  the  bend  of  the  elbow  the 
two  lateral  groups  come  more  and  more  to 
the  anterior  surface  of  the  limb  and  unite 
with  the  median  group  :  on  the  dorsal  sur- 
face we  find  nothing  but  some  rather  small 
collecting  trunks,  which  incline  obliquely, 
some  outwards,  others  inwards,  and  reach 
the  anterior  surface  of  the  arm  (vide  Fig. 
91).  At  the  level  of  the  olecranon  these 
collecting  trunks  present  remarkable  sinu- 
osities. 

In  the  arm,  the  different  collecting 
trunks,  henceforth  united  into  a  single 
bundle,  show  a  tendency  to  arrange  them- 
selves on  the  external  surface  of  the  arm. 
parallel  to  each  other. 

TERMINATION  :  The  majority  of  these  col- 
lectors run  as  far  as  the  neighbourhood  of 
the  base  of  the  axilla.  Here,  they  per- 
forate the  deep  fascia,  and  terminate  in 
the  humeral  chain  of  axillary  glands.  The 
collectors  from  the  outermost  and  inner- 
most parts  have  quite  a  different  termina- 
thus  two  or  three  of  the  most  internal 


Fid  9(1.— Superficial  lym- 
phatics of  the  arm, 
anterior  surface  (after 
Sappey). 


1,1.  Lymphatic  network  of  the  fingers.  '2,  "2.  Lym- 
phatic network  of  the  palm  of  the  hand.  3.  External 
collateral  lymphatic  trunk  of  the  thumb.  4,  4. 
Vessels  which  arise  from  the  network  of  the  palmar 
surface.  5,  5.  Trunks  which  come  from  the  postero- 
external  part  of  the  hand  and  forearm.  6,  6.  Trunks  coming  from  the  postero-internal 
parts.  7.  Supra-epitrochlear  gland,  into  which  some  of  these  trunks  pass.  8.  Second 
gland  which  is  sometimes  found  above  the  preceding.  9,  9.  Collection  of  trunks  which 
occupy  the  anterior  surface  of  the  arm.  10.  Largo  trunk  which  occupies  the  interval 
between  the  deltoid  and  pectorali?  major.  11.  Gland  situated  in  the  course  of  this  trunk. 
12,  12.  Semicircular  section  of  integuments.  13.  Axillary  glands. 


LYMPHATICS    OF    THE    UPPER    LIMB 


245 


end  in  the  supra-epitrochlear  gland.  We 
have  already  seen  that  the  efTerents  of  this 
gland  perforated  the  deep  faseia  in  the  middle 
part  of  the  arm  and  end  in  the  deep  vessels. 
When  this  gland  is  absent,  we  may  never- 
theless see  the  internal  collectors  perforating 
the  fascia  at  the  same  point  to  reach  the 
deep  absorbents.  The  most  external  trunk  is 
also  remarkable  for  the  special  course  it 
pursues.  It  separates  itself  from  the  other 
collectors  in  the  region  of  the  humeral  inser- 
tion of  the  deltoid,  then  ascends  in  the  delto- 
pectoral  groove,  where  it  may  traverse  one 
or  several  glands  which  Ave  have  indicated 
above  (vide  pp.  234  and  235).  This  trunk  usually 
passes  into  a  subclavian  gland,  placed  at  the 
spot  where  the  cephalic  joins  the  axillary 
vein.  It  may  also  be  seen  to  pass  above  the 
clavicle,  and  to  empty  itself  into  a  supra- 
clavicular  gland.  This  arrangement,  though 
somewhat  infrequent,  has  been  figured  by 
Mascagni  (loc.  cit.,  tab.  xix.).  This  delto- 
pectoral  trunk  is  sometimes  double  and  even 
triple. 

DEEP  LYMPHATICS. — The  deep  lymphatics 
follow  the  brachial  artery  and  its  chief  branches. 
There  are  usually  two  lymphatic  trunks  for 
each  artery.  With  Sappey,  we  will  divide 
these  deep  lymphatics  into  radial,  cubital, 
posterior,  interosseous,  anterior  interosseous, 
and  brachial. 

The  radial  trunks  arise  from  the  subfascial 
portions  of  the  palm  of  the  hand.  "  One 
accompanies  the  deep  palmar  arch,  turns 
round  the  head  of  the  first  metacarpal  bone, 
and  runs  on  the  outer  side  of  the  carpus,  and 
reaches  the  forearm,  where  it  is  situated  on 
the  external  side  of  the  radial  artery ;  the 


into    two   groups,  of   which   one    runs  inwards,   and   the  other 
which   arise    from    the    posterior   surface    of    the  arm.     6,    6. 
integuments  of  the  shoulder. 


.4 


FIG.  91. — Superficial  lym- 
phatics of  the  upper 
limb  (posterior  surface) 
(Sappey). 

1,  1.  Lymphatic  net- 
work of  the  dorsal  surface 
of  the  fingers.  2,  2.  Col- 
lection of  trunks  which 
cover  the  back  of  the  hand. 
3,  3.  Trunks  which  run 
over  the  posterior  surface 
of  the  forearm.  4,  4. 
These  same  trunks  which, 
at  the  elbow,  become 
extremely  sinuous,  divide 
outwards.  5,  6.  Vessels 
Vessels  coming  from  the 


246  SPECIAL    STUDY    OF    THE    LYMPHATICS 

other,  whose  origin  is  not  so  deep,  follows,  according  to  the  sketch 
left  us  by  Mascagni,  the  course  of  the  radio-palmar  artery,  and 
also  joins  the  forearm,  where  it  is  placed  on  the  inner  side  of  the 
radial.  Both  then  ascend  as  far  as  the  bend  of  the  elbow,  where 
they  anastomose.  In  their  anti-brachial  course,  they  traverse 
one  or  two  small  glands,  the  existence  of  which  is  not  constant  " 
(Sappey). 

The  ulnar  trunks  are  also  two  in  number.  They  have  a  separate 
origin.  One,  in  fact,  appears  by  the  side  of  the  superficial  palmar, 
while  the  other  is  a  satellite  of  the  deep  palmar  arch.  They  unite 
at  the  wrist,  just  above  which  they  receive  a  large  affluent  which 
is  a  satellite  of  the  dorsal  branch  of  the  ulnar.  They  then  run 
parallel  to  the  ulnar  vessels  as  far  as  the  bend  of  the  elbow.  During 
their  course  they  sometimes  present  one  or  more  small  glands. 

The  posterior  interosseous  trunks,  which  arise  from  the  deep 
muscles  of  the  forearm,  perforate  the  interosseous  membrane  and 
then  unite  at  the  bend  of  the  elbow,  Avith  the  preceding  vessels. 

The  anterior  interosseous  trunks  follow  the  vessels  of  this  name, 
and,  after  presenting  in  their  course  one  or  two  small  glands,  also 
end  in  the  lymphatic  meeting-place  at  the  bend  of  the  elbow. 

The  humeral  trunks  comprise  all  the  above  -  mentioned  anti- 
brachial  collecting  trunks.  They  vary  from  2  to  3  in  number. 
They  run  by  the  side  of  the  humeral  vessels,  and  terminate  in 
the  humeral  group  of  the  axillary  glands.  As  we  have  already 
seen,  they  present  in  their  course  some  small  glands  which  appear 
to  be  nearly  alwa}rs  present.  In  the  middle  part  of  the  arm,  they 
collect  the  efferent  vessels  from  the  supra-epitrochlear  gland.  They 
also  receive  some  small  trunks  from  the  muscles  of  the  arm 
(Mascagni,  loc.  cit.,  plate  xxv.). 

TECHNIQUE. — The  method  employed  for  the  injection  of  the  lymphatics 
of  the  upper  limb  is  almost  the  same  as  that  indicated  for  the  lower  limb 
(vide  pp.  126  and  127).  The  most  suitable  points  for  the  primary  punctures 
are  the  palmar  and  lateral  surfaces  of  the  fingers- 


CHAPTER   V 
LYMPHATICS   OF   THE    HEAD  AND  NECK 

WE  will  study  in  turn:  (1):  the  glandular  groups  of  the  head  and 
neck  ;  (2).  the  lymphatic  apparatus  of  the  different  organs  whose 
vessels  are  tributaries  of  these  glands. 

§  1.  GLANDULAR  GROUPS  OF  THE  HEAD  AND  NECK. 

The  glandular  apparatus  of  the  head  and  neck  presents  a  con- 
siderable degree  of  development.  It  is,  moreover,  in  the  cervical 
region  that  the  first  glands  appear  in  the  course  of  phylogenic 
development. 

The  general  arrangement  of  these  glands  may  be  classified  as 
follows  :  they  form  at  first  a  kind  of  circle,  a  true  glandular 
collar,  placed  at  the  junction  of  head  and  neck.  From  this,  runs 
on  either  side  a  vertical  chain  which  stretches  'underneath  the 
sterno-mastoid,  and  accompanies  the  vessels  and  nerves  as  far  as 
the  junction  of  the  neck  with  the  thorax.  This  principal  chain 
is  flanked  by  several  secondary  chains  of  less  importance. 

1.   PERI-CERVICAL    GLANDULAR    CIRCLE. 

This  glandular  circle  is  divisible  into  a  certain  number  of  groups, 
which  are  named  according  to  the  region  they  occupy.  Working 
from  behind  forwards  we  shall  have  to  distinguish  : — 

1.  The  sub-occipital  group  and   the  aberrant  glands  of   the  nape 
of  the  neck  which  hang  from  it. 

2.  The  mastoid  group. 

3.  The  parotid  and  sub-parotid  groups. 

4.  The  sub-maxillary  group,   of    which   the  facial  glands    form 
an  offshoot. 

5.  The  sub-mental  glands. 

6.  Finally,  the  retro-pharyngeal  glands,  which    may  be    included 
with  the  preceding  groups. 

1.  THE    SUB-OCCIPITAL     GLANDS. — The    number    of     occipital 


247 


248 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


glands  varies  from  1  to  3.  We  have  found  2  the  most  usual  number. 
These  glands,  which  are  the  size  of  a  pea.  are  flattened  and  circular, 
and  usually  rest  close  to  the  occipital  insertion  of  the  complexus 
muscle,  immediately  external  to  the  external  border  of  the  trapezius. 

More  rarely  they  are 
placed  on  this  muscle, 
and  in  this  case  they  are 
in  intimate  connexion  with 
the  terminal  filaments  of 
the  great  occipital  nerve. 
Tiie  sub-occipital  glands 
are  always  sub-aponeu- 
rotic. 


One  of  the  present  writers 
found  in  several  subjects, 
injected  by  Gerota's  method, 
a  gland  placed  on  tiie  pos- 
terior surface  of  the  trapezius, 
at  the  level  of  the  spinous 
process  of  the  fourth  cervical 
vertebra.  This  gland  may  be 
regarded  as  an  aberrant 
element  belonging  to  the 
sub-occipital  group. 

The  s  u  b-o  c  c  i  p  i  t  a  1 
glands  receive  their  affer- 
ent lymphatics  from  the 

the    glandular    OC(jipital     portion     of     the 

Parotid  hairy  scalp.  IL\\Q\V  efferent 
vessels  run  downwards 
and  forwards,  some  cours- 
ing above,  and  others  below  the  splenius.  They  terminate  in 
the  highest  glands  of  the  substerno-mastoid  group.  We  shall 
see  later  on  that  these  latter  also  receive  vessels  coming 
directly  from  the  occipital  region. 

2.  MASTOID  GLANDS  (Retro-auricular  glands). — The  mastoid 
glands  are  usually  two  in  number.  Always  clearly  visible  in  the 
infant,  they  are  often  difficult  to  find  in  the  adult.  They  are 
usually  placed  one  behind  the  other,  and  are  united  by  two  or 
three  lymphatic  trunks.  They  are  subjacent  to  the  inferior  border 
of  the  retrahens  aurem,  and  lie  on  the  mastoid  insertion  of  the  sterno- 
mastoid.  A  fine  fibrous  layer,  which  springs  from  the  sheath  of 
the  sterno-mastoid,  fixes  them  on  to  this  muscle. 


of 


fans 

FIG.    92. — General    arrangement 

groups  of  the  head  and  neck. 

a.  Occipital  glands,     b.  Mastoid  glands, 
glands,      d.  Submaxillary    glands.       e.  Facial   gland 
/.  Submental  glands,     g.  Deep  cervical  chain. 


LYMPHATICS  OF  THE  HEAD  AND  NECK 


249 


The  mastoid  glands  receive  their  afferents  from  the  temporal 
portion  of  the  hairy  scalp,  from  the  internal  surface  of  the  auricle, 
with  the  exception  of  the  lobule,  and  from  the  posterior  surface 
of  the  external  auditory  meatus. 

Their  efferent  trunks  empty  themselves  into  the  superior  glands 
of  the  sub-sterno-mastoid  group,  after  traversing  the  superior 
insertions  of  this  muscle.  Some  authors  wrongly  connect  these 
deep  glands  with  the  mastoid  glands,  which  they  then  reckon  as 
being  4  or  G  in  number. 

3.  PAROTID  GLANDS. — The  parotid  group  contains  several 
masses,  viz. 
the  s  u  b- 
cutaneous 
glands,  the 
glands  con- 
tained in 
the  parotid 
space,  and 
th  e  s  u  b  - 
parotid 
glands. 

(a)  The 

existence    of  sub-cutaneous 
authors,    and    notabh 


Xasal  lytnphatics 


Intxtnal 
juj  ular 


uryngeal  gland 
I'tiruitd  yhind 
Pftrr>tiil  ylrtnd 
Parotid  gland 

3t&-pttrotid  gland 


FIG.  93. — Scheme  of  the  parotid  ami  sub-parotid  glands. 


glands  is  admitted  by  different 
by  Richet  (Anatomie  Medico-cMrurgicale, 
4th  edition,  p.  193),  and  by  Merkel  (Topogr.  Anat.,  vol.  i.  p.  454). 
Sappey  formally  denies  their  existence.  Without  going  as  far 
as  this,  however,  we  may  say  that  they  are  usually  absent. 

(b)  The  glands  contained  in  the  parotid  space  are  situated,  either 
external  to  the  gland,  immediately  beneath  the  parotid  fascia 
(superficial  glands),  or  in  the  actual  substance  of  the  parotid  (deep 
glands). 

The  superficial  glands  are  usually  placed  immediately  in  front 
of  the  tragus.  Sometimes  2  or  3  in  number,  they  are  not  infre- 
quently reduced  to  a  single  gland — the  prae-auricular  gland  of 
authors  (vide  Fig.  92). 

The  deep  glands  are  scattered  throughout  the  entire  gland,  but 
are  usually  grouped  along  the  external  jugular  and  external  carotid 
vessels.  According  to  Poulsen  (quoted  by  Stahr),  one  of  these 
glands  constantly  occupies  the  lower  part  of  the  space,  and  is  at- 
tached close  to  the  angle  of  the  jaw,  in  contact  with  the  deep  cervical 
fascia. 


250 


SPECIAL    STUDY    OF    THE   LYMPHATICS 


The  parotid  glands  receive  their  afferent  lymphatics  from  the  exter- 
nal surface  of  the  auricle,  from  the  external  auditory  meatus.  from 
the  tympanum,  from  the  skin  of  the  temporal  and  frontal  regions, 
from  the  eyelids  and  root  of  the  nose  (Kiittner).  They  perhaps 
also  receive  vessels  coming  from  the  mucous  membrane  of  the 
nasal  fossae  and  from  the  posterior  part  of  the  alveolar  border  of 
the  superior  maxilla.  Their  efferent  vessels  pass  into  the  glands 
grouped  round  the  spot  where  the  external  jugular  vein  leaves 
the  parotid,  and  into  the  sub-sterno-mastoid  glands. 

The  number  of  glands  contained  in  the  parotid  space  is  very 

difficult  to  esti- 
mate even  ap- 
proximately. 
Though  their 
browner  colour 
enables  us  to 
distinguish 
them  from  the 
parotid  lobules, 
they  are  diffi- 
cult to  recog- 
n  i  z  e  unless 
their  afferent 
vessels  have 
been  injected. 
On  the  other 
hand,  in  speci- 
mens treated 
by  Ge rota's 
method,  we  can 
convince  our- 
selves that  they 

exist  in  considerable  numbers  (10  to  16).  Histological  examina- 
tions prove  them  to  exist  in  still  greater  numbers,  for  we  can 
then  see  minute  glands  which  are  invisible  in  an  ordinary  dissec- 
tion. The  microscope,  too,  enables  us  to  demonstrate  the  presence 
of  lymphoid  masses  of  variable  shapes  and  sizes  which  surround 
the  acini,  and  are  analogous  to  the  formations  pointed  out  by 
Rawitz  in  the  submaxillary  gland. 

When  the  parotid  lymphatic  glands  are  studied  histologically,  especially  in 
the   new-born,   one  is    struck    by     finding   glandular     acini     in   several    of 


FIG.   94. —Section    of   a    parotid    gland   (foetus  of  twenty-one 

centimetres)  (Xeisse). 

In  this  figure  may  be  seen  tho  invasion  of  the  lymphatic  gland 
by  several  glandular  acini  which  hove  penetrated  into  the  gland 
as  far  as  the  hilurn  and  show  a  tendency  to  reach  its  cortical 
substance. 


THE    LYMPHATICS    OF    THE    HEAD    AND    NECK      251 

them.  These  acini,  though  sometimes  confined  to  the  medullary  portion 
of  the  gland,  may  pass  as  far  as  its  cortical  zone  arid  even  compress  the 
glandular  tissue  which  is  reduced  to  a  fine  shell  surrounding  the  glandular  bud. 
This  is  clearly  a  case  of  an  active  penetration  of  acini  into  the  interior  of  lym- 
phatic glands.  In  studying  sections  of  a  foetus  from  three  to  six  months 
old,  Xeisse  was  able  to  follow  all  the  stages  of  this  penetration.  We  must 
not,  however,  confuse  this  invasion  of  lymphatic  glands  by  the  elements  of 
the  secreting  gland,  with  the  peri-acinous  lymphoid  infiltration  mentioned 
above.  We  should  add  that  this  penetration  of  the  acini  into  the  lymphatic 
glands  is  easily  explained  by  the  absence  of  encapsulation  both  of  the  salivary 
and  of  the  lymphatic  glands  in  the  initial  stages  of  their  development. 

From  a  pathological  point  of  view,  we  may  ask  whether  certain  cases  of 
glandular  tuberculosis,  which  are  apparently  primary,  may  not  be  explained 
by  these  intimate  connexions  of  certain  acini  with  the  lymphatic  glands 
whose  bacillary  invasion  is  so  frequent  (?). 

Vide  R.  Neisse  Ueber  den  Einschluss  von  Parotislappchen  in  Lymph- 
knoten.  An.  Hefte  v.  Merkel  u.  Bonnet.  Erste  Abth.,  1898,  x,  p.  287. 

(c)  Sub-parotid  Glands. — The  sub-parotid  glands  are  placed 
between  the  parotid  and  the  pharynx,  in  the  latero-pharyngeal, 
or  posterior  sub-glandular  space.  They  are  in  contact  with  the 
carotid  and  internal  jugular  veins.  These  glands  are  the  starting- 
point  of  latero-pharyngeal  abscess.  They  receive  their  afferent 
vessels  from  the  nasal  fossae,  from  the  nasal  pharynx,  and  from  the 
Eustachian  tube.  Their  efferents  pass  into  the  glands  of  the  great 
deep  cervical  chain. 

The  majority  of  authors  do  not  mention  the  existence  of  glands 
in  the  anterior  sub-glandular  space.  Quain,  however,  mentions 
some  small  glands  placed  in  the  course  of  the  internal  maxillary. 
Leaf  has  never  met  with  the  glands  described  by  Quain,  but  has 
seen,  on  the  contrary,  a  small  gland  on  the  outer  surface  of  the 
external  pterygoid  muscle  immediately  behind  the  frontal  process 
of  the  malar  bone. 

4.  SUBMAXILLARY  GLANDS  (lateral  supra-liyoid  glands).  --  The 
number  of  submaxillary  glands  varies  from  3  to  6.  They  form 
a  ring  stretching  along  the  inferior  border  of  the  maxilla,  from  the 
insertion  of  the  anterior  belly  of  the  digastric  to  the  angle  of  the 
jaw.  They  are  therefore  placed  at  the  junction  of  the  cutaneous 
and  bony  surfaces  of  the  submaxillary  gland,  upon  which  they  rest. 
They  vary  in  size  from  a  pea  to  a  haricot  bean.  The  largest  and 
most  constant  of  them  usually  occupies  the  centre  of  the  chain 
(the  middle  gland  of  Stahr),  and  corresponds  to  the  spot  where  the 
latter  is  crossed  by  the  facial  artery.  It  is  frequently  found  that 
one  of  these  glands  isolates  itself  from  the  chain,  and  is  situated 
over  the  course  of  the  facial  vein  in  the  middle  of  the  cutaneous 


252  SPECIAL    STUDY    OF    THE    LYMPHATICS 

surface  of  the  submaxillary.  On  the  other  hand,  it  is  more  rare 
to  meet  with  the  glands  noticed  by  Leaf  and  Kiittner,  on  the  in- 
ternal surface  of  the  gland.  All  the  submaxillary  glands  are  sub- 
fascial. 

The  number  of  submaxillary  glands  is  very  differently  estimated 
by  authors.  Roughly  speaking,  we  may  say  that  the  numbers 
given  by  the  older  writers  are  much  higher  than  we  have  allowed. 
W.  Krause,  Henle,  Rauber,  and  Merkel  speak  of  3  to  10  ;  Sappey, 
12  to  15.  With  Gussenbauer,  Leaf,  and  Stahr,  we  think  these 
estimates  are  much  too  high,  and  that  if  we  simply  count  the 
glands  which  can  be  seen  after  a  simple  dissection,  and  after  in- 
jection of  their  afferents,  we  shall  find  that  they  rarely  exceed  5 
or  6. 

Contrary  to  what  we  have  noticed  in  the  case  of  the  parotid,  there  do 
not  appear  to  be  any  lymphatic  glands  included  in  the  submaxillary  salivary 
gland.  We  may  remark,  however,  that  in  the  cercopithekos  (long-tailed 
monkey),  Rawitz  has  seen  in  the  submaxillary  gland,  lymphoid  masses  sur- 
rounding the  acini.  But  these  structures  are  essentialhr  variable  in  their 
size  and  arrangement  and  even  in  their  existence,  and  should  not  be  regarded 
as  true  lymphatic  glands. 

The  submaxillary  glands  receive  as  afferents  the  lymphatics  of 
the  nose,  the  cheek,  the  upper  lip,  and  the  external  part  of  the 
lower  lip,  almost  the  whole  of  the  gums,  and  the  anterior  third  of 
the  lateral  border  of  the  tongue  (vide  p.  275). 

Their  efferent  vessels  descend  on  the  cutaneous  surface  of  the 
submaxillary  gland,  cross  the  hyoid  bone  and  terminate  in  the 
glands  of  the  deep  cervical  chain,  and  more  particularly  in  the 
glands  over  the  bifurcation  of  the  common  carotid.  One  or  two 
of  these  trunks  may,  however,  end  in  a  gland  situated  much  deeper, 
viz.  at  the  point  where  the  omo-hyoid  crosses  the  internal  jugular 
vein. 

BIBLIOGRAPHY. — H.  Stahr.  Zahl  und  Lage  der  submaxillaren  Lymph- 
drusen,  Arch.  /.  Anat.  u.  Phys.  Anat.  Abth.,  1898,  p.  144. — Rawitz,  Ueber 
Lymphknotenbildungeii  in  Speicheldrusen,  An.  Anz.  ;  Bd.  14,  n  17-18, 
p.  463. 

Facial  Glands. — The  afferent  vessels  of  the  submaxillarv 
glands  frequently  traverse  (20  times  in  32  subjects  according  to 
Princeteau)  some  small  glands,  usually  described  as  genial  glands, 
but  which,  we  think,  are  more  suitably  described  under  the  more 
comprehensive  term  of  facial  glands. 

These  glands  form  three  groups  placed  one  above  the  other  in 
the  course  of  the  facial  vessels  : 

(1)  The  inferior  or  supra-maxillary  group  rests  on  the  external 


LYMPHATICS  OF  THE  HEAD  AND  NECK 


253 


FIG.  9f>.  —Facial  glands  (after  Buchbinder). 
«.  Infra-maxillary  gland,  h.  Snt--n:a.xillary 
gland,  c.  Buccinator  glaiKl  (middle  mass;. 
d.  Buccinator  gland  (posterior  mass).  e 
Gland  of  the  naso-gcnial  groove.  /.  Sul>- 
lorbital  gland. 


surface  of  the  inferior  maxilla  between  the  anterior  border  of  the 
masse ter  and  the  posterior   border  of  the  depressor  anguli  oris, 
and  beneath  the  platysma.     This  group  comprises  1  to  13  glands 
which    are    in    intimate    con- 
nexion   with    the    artery    and 

the    facial    vein.     It  wras   met  1& 

Avith  by  Princeteau  fourteen 
times  in  thirty-two  subjects 
(vide  &,  Fig.  95).  It  is  some- 
times joined  to  the  submaxil- 
lary  group  by  a  gland  which 
is  placed  on  the  actual  lower 
edge  of  the  inferior  maxilla  ; 
this  is  the  infra-maxillary  gland 
(a,  Fig.  95). 

(2)  The  middle  or  buccinator 
group     is      somewhat     deeply 
situated    on    the  external  sur- 
face of  the  buccinator  muscle. 
It    is    less    frequently    present 
than    that    of    the    preceding 

group  (ten  times  in  thirty-two  subjects,  Princeteau).     It  includes 
three  distinct  masses,  which  may  exist  together  or  separately. 

(a)  A  posterior  or  retro- vascular  mass  formed  by  one  or   two 
glands   situated   behind   the   facial   artery,   where   Stenson's   duct 
perforates  the  buccinator.     This  group  must  not  be  confused  with 
the  salivary  glands  which  may  be  found  in  this  region  (d,  Fig.  95). 

(b)  A  middle  inter-vascular  mass  which  usually  consists  of  two 
glands,  placed  between  the  artery  and  the   vein.     This   mass  is 
covered  by  the  posterior  fibres  of  the  zygomaticus  major  (c,  Fig.  95). 

(c)  An  anterior  prae-vascular  gland  may  exceptionally   be  met 
with,  situated  on  the  external  surface  of  the  orbicularis  oris,  in  the 
subcutaneous  cellular  tissue,   8  to   10  millimetres  from   the  labial 
commissure.     This  is  the  commissural  gland  of  Princeteau. 

All  these  buccinator  glands  lie  above  the  buccal  fascia  ;  Debierre, 
however,  points  out  the  possible  existence  of  subfascial  glands. 
Poncet  has  even  met  with  a  submucous  gland. 

(3)  The  superior  group  is  of  much  less  importance  than  the  two 
preceding,  and  comprises  several  glands,  viz.  a  gland  of  the  naso- 
genial  groove,  pointed  out  by  Tillaux  and  also  found  by  Princeteau 
(e,  Fig.  95),  asuborbital  gland  (/,  95),  and  a  malar  gland,  the  exist- 

Q 


254  SPECIAL    STUDY    OF    THE    LYMPHATICS 

ence  of  which  has  hardly  been  proved  except  clinically  (Albert in, 
Vigier). 

The  majority  of  the  older  writers  (Richet,  Paulet,  Beaunis  and  Bouchard, 
Sappey,  etc.,  do  not  mention  the  facial  glands.  Mascagni,  however,  as 
long  ago  as  1787,  had  observed  and  described  the  facial  glands  and  even 
distinguished  the  supra-maxillary  and  buccinator  groups.  Boyer,  Cloquet, 
Bourgery  and  Jacob,  and  Cruveilhier  mention  them  briefly.  More  recently 
(1887)  the  clinical  observations  of  Poncet  have  again  drawn  attention  to 
this  point  and  several  authors  (Jaboulay,  Vigier,  Princeteau,  Buchbinder, 
etc.)  have  resumed  the  study  of  them. 

BIBLIOGRAPHY. — MASCAGNI,  loc.  cit.,  p.  61,  pi.  XXVI,  Fig.  1. — VIGTER.  1  )<?> 
adenites  de  la  joue.  Gaz.  hebd.,  1892,  et  Th.  de  Lyon,  1892. — ALBERTIN.  Adenites 
geniennes.  Arch.  prov.  de  Chir.,  1895. — PRINCETEAU.  Les  ganglions  lympha- 
tiques  de  la  joue,  Gaz.  hebd.  des  sc.  med.  de  Bordeaux,  1899. — CAPETTE-LAPLKNE. 
Les  ganglions  de  la  joue,  Th.  Bordeaux,  1899. — BUCHBINDER.  Ueber  die  Lage 
u.  die  Erkr.  der  Wangenlymphdrusen,  Beitr.  z.  klin.  Chir.,  1899.  THEVEXOT. 
Des  adenites  geniennes,  Gaz.  des  Hopitaux,  21  avril  1900 

5.  SUBMENTAL  GLANDS  (Synonym  Supra-hyoid  median  glands). 
— Under  the  term  submental  glands  are  described  the  glands  con- 
tained in  the  triangle  bounded  by  the  anterior  bellies  of  the  two 
digastric  muscles  and  the  hyoid  bone.  The  number  of  these  glands 
vary  from  1  to  4.  Their  arrangement  is  extremely  variable  ; 
usually  two  in  number,  they  are  either  transverse,  in  which  case 
they  are  more  or  less  in  close  proximity  to  the  middle  line,  or  else 
they  are  vertical.  In  the  latter  case,  one  is  in  close  proximity  to 
the  mandible,  and  the  other  to  the  hyoid  bone.  A  gland  placed 
on  the  anterior  belly  of  the  digastric  sometimes  constitutes  a 
transition  stage  between  this  group  and  the  submaxillary  glands. 

The  submental  glands  receive  their  afferent  vessels  from  the 
integuments  of  the  chin,  from  the  central  portion  of  the  skin  of  the 
lower  lip,  from  the  mucous  membrane  of  the  corresponding  portion 
of  the  alveolar  border  of  the  mandible,  from  the  floor  of  the  mouth, 
and  finally  from  the  tip  of  the  tongue  (on  this  latter  origin,  which 
is  elsewhere  discussed,  vide  p.  274). 

Their  efferent  vessels  follow  a  double  course.  Three  or  four 
trunks  run  outwards  towards  the  submaxillary  glands.  One  or 
two  others  are  directed  downwards,  cross  the  hyoid  bone  and  ter- 
minate in  a  gland  placed  on  the  anterior  surface  of  the  internal 
jugular  vein,  above  the  point  where  the  latter  is  crossed  by  the 
omo-hyoid.  One  of  these  vessels  sometimes  describes  a  remark- 
able loop  in  front  of  the  sub-hyoid  muscles. 

(6)  RETRO-PHARYNGEAL  GLANDS. — The  retro-pharyngeal  glands 
are  placed  behind  the  pharynx,  at  the  junction  of  its  posterior  and 
lateral  surfaces,  at  the  apex  of  the  lateral  masses  of  the  atlas. 


LYMPHATICS  OF  THE  HEAD  AND  NECK 


255 


These  glands  are  usually  2  in  number.  According  to  Most, 
however,  it  is  the  rule  for  one  gland  only  to  be  present.  When 
these  glands  are  2  in  number,  they  lie  over  one  another  in  the  ver- 
tical plane. 

These  glands  are  in  relation  :    in  front,  with  the  posterior  wall 


FIG.  90.— Retro-pharyngeal  gla:ids. 

a,  b.  Retro-pharyngeal  glands,  c..  Interrupting  glandular  nodulo,  placed  in  the  course 
of  the  afferent  vessels  of  these  glands,  d.  Gland  of  the  deep  cervical  chain.  e.  Efferent 
vessel  of  retro-phnryngeal  gland?,  passing  in  front  of  the  internal  carotid  artery.  /  Afferent 
of  the  retro-pharyngeal  glands,  passing  behind  the  right  rectus  capitis  anticus  major. 
g.  Lymphatic  of  the  pharynx,  passing  directly  to  a  gland  of  the  deep  cervical  chain,  h. 
Afferent  of  retro-pharyngeal  glands. 


of  the  pharynx  ;  behind,  with  the  rectus  capitis  anticus  major, 
which  separates  them  from  the  lateral  masses  of  the  atlas  ;  exter- 
nally, with  the  constrictors  of  the  pharynx,  and  through  the  latter, 
with  the  internal  carotid  artery  ;  internally,  they  are  nearly  2 
centimetres  distant  from  the  middle  line  (vide  Figs.  93  and  96). 

These  glands  are,  as  has  been  seen,  purely  lateral.  If,  in  the  case  of  a  retro- 
pharyngeal  abscess,  the  collection  of  pus  tends  to  become  central,  the  reason 
probably  is  that  the  abscess  cavity  being  confined  externally  by  the  con- 
strictors, cannot  extend  in  that  direction,  but  can  do  so  internally  where 
there  is  nothing  to  hinder  it. 

We  may,  however,  find  one  or  several  small  glands  lying  near  the  middle 
line,  or  on  a  level  with  it.  Most  even  points  out  as  a  fairly  frequent  occur- 
rence, a  gland  placed  in  front  of  the  odontoid  process ;  but  these  are  incon- 
stant. These  very  small  glands  are  moreover  simple  interrupting  glandular 
nodules  placed  in  the  course  of  the  afferents  of  the  retro-pharyngeal  glands 
properly  so  called 


256  SPECIAL   STUDY    OF    THE    LYMPHATICS 

The  retro-pharyngeal  glands  receive  as  afferents  almost  all  the 
collectors  coming  from  the  mucous  membrane  of  the  nasal  fossae, 
and  the  cavities  in  connection  with  it,  the  lymphatics  of  the  nasal 
pharynx,  those  of  the  Eustachian  tube,  and  perhaps  some  of  the 
lymphatics  from  the  cavity  of  the  tympanum.  As  has  been  seen, 
their  lymphatic  area  is  very  extensive,  and  the  frequent  infection 
of  these  glands  is  easily  explained. 

The  efferent  vessels  of  the  retro-pharyngeal  glands  empty  them- 
selves into  the  superior  glands  of  the  internal  jugular  chain.  To 
reach  these,  they  pass,  for  the  greater  part,  behind  the  vessels  and 
nerves,  and  more  particularly  the  superior  cervical  gland,  the 
posterior  surface  of  which  they  cross.  Some  of  them,  however, 
pass  in  front  of  the  internal  carotid  artery  and  external  jugular 
vein  to  reach  their  new  glandular  relay  (vide  e,  Fig.  96). 

Owing  to  the  practical  importance  of  the  retro-pharyngeal  glands  several 
works  have  been  produced.  We  will  only  mention  the  most  important : 
Mascagni,  loc.  cit.,  p.  63. — Tourtual.  Neue  Untersuchungen  iiber  der  Base 
des  menschlich.  Schlund.  und  Kehlkopfes.  Leipzig,  1846. — Gillette.  Th. 
Paris,  1867. — Bokai.  Ueber  Retropharyngealabcess.  Jahrb.  f.  Kinderkrank., 
I,  1887. — Moreau.  Contribution  a  1' etude  des  abces  retro-pharyngiens.  Th. 
Paris,  1896. — Most.  Zur  Topographic  und  Aetiologie  der  retro-pharyngealeii 
Drusenacbesse.  Arch.  f.  klin.  Chir.,  LXI,  3. 

2.    DESCENDING    CERVICAL  CHAINS. 

We  have  seen  that  from  the  glandular  collar  formed  by  the 
different  groups  which  we  have  just  been  studying,  a  chain  of 
glands  detached  itself  on  either  side,  and  descended  with  the  large 
vessels  as  far  as  the  root  of  the  neck.  This  is  the  deep  cervical 
chain.  This  principal  chain  is  flanked  by  several  secondary 
chains  of  more  or  less  importance,  viz.  the  external  jugular 
chain,  the  two  anterior  cervical  chains,  superficial  and  deep,  and 
the  recurrent  chain. 

Deep  Cervical  Chain. — The  deep  cervical  chain  (carotid  chain, 
substerno-mastoid ,  deep  glands  of  the  neck)  constitutes  one  of  the 
most  important  of  the  glandular  regions  of  the  system.  It  com- 
prises from  15  to  30  glands,  but  this  number  is  apt  to  vary  con- 
siderably. Here,  as  is  always  the  case,  the  number  apparently 
varies  inversely  as  the  size  (vide  pp.  84  and  85).  In  certain  patho- 
logical cases,  it  seems  as  though  there  is  an  actual  increase,  but 
this  is  only  because  glands  which  in  the  normal  state  were  imper- 
ceptible, are  now  rendered  visible. 

The  deep  cervical  chain  realty  constitutes  a  large  mass  which 
extends  beneath  the  sterno-mastoid,  and  in  the  subclavian  tri- 


LYMPHATICS  OF  THE  HEAD  AND  NECK 


257 


angle  disappears  behind  this  muscle  ;  further,  although  this 
glandular  layer  is  in  reality  continuous,  we  may  regard  it  as  being 
formed  of  two  groups  :  viz.  the  sub-sterno-mastoid  and  the 
supra-clavicular  group  (vide  Fig.  92). 

1.      S  u  B- 

STERNO-MAS-  /  ^^ 
TOID  GLANDS. 
—This  group 
extends  in  the 
vertical  plane 
from  the  tip 
of  the  mas- 
toid  process 
and  the  pos- 
terior belly  of 
the  digastric 
to  the  junc- 
tion of  the 
internal  jugu- 
lar and  sub- 
clavian,  but 
it  is  in  the 

Upper  part    OI       gterno-mastoid    gland    (external  group).       d.    Gland  of  the  external 
this     region       jugular  chain,  e.  Sterno-mastoid  gland  (internal  group,  internal  jugular 
chain).     /.    Sub-hyoicl  aberrant  gland,   placed   in    the  course   of    the 
that          the       efferent  vessels  of  the  sub-mental  glands. 

glands  are 

most  numerous  and  largest.  Frequently  indeed,  this  group 
does  not  descend  below  the  point  where  the  omo-hyoid  crosses 
the  vessels  and  nerves.  All  these  glands  are  covered  by  the 
sterno-cleido-mastoid,  and  are  adherent  to  the  deep  layer  of  the 
sheath  of  this  muscle, 

Though  they  constitute  in  appearance  a  continuous  glandular 
laver,  we  may  divide  them  into  two  groups  :  an  external  and  an 
internal,  differing  in  their  general  arrangement,  and  in  the  source 
of  their  afferent  vessels. 

(1)  The  external  glands  are  placed  behind  and  external  to  the 
internal  jugular  vein.  Usually  of  small  size,  round  and  scattered 
apparently  indiscriminately,  these  glands  rest  on  the  insertions  of 
the  splenius,  levator  anguli  scapulae,  and  the  scalene  muscles. 
They  are  embedded  in  the  cellulo-adipose  tissue  which  surrounds 
the  branches  of  the  deep  cervical  plexus.  At  the  level  of  the 


FIG.   97. — Deep  Orvical  Chain. 
Collectors  of  the  fossa  of  the  auricle.      /«.  Mastoid  glands,     c. 


258  SPECIAL    STUDY    OF    THE    LYMPHATICS 

posterior  border  of  the  sterno-mastoid,  they  are  continuous  without 
any  line  of  demarcation  with  the  glands  occupying  the  subclavian 
triangle.  In  this  external  group  in  particular,  the  cutaneous  lym- 
phatics from  the  posterior  segment  of  the  head  and  upper  portion 
of  the  neck,  terminate. 

(2)  The  internal  glands  (internal  jugular  chain)  rest  on  the  in- 
ternal jugular,  or  are  immediately  adjacent  to  its  external  border 
(vide  Figs.  97  and  105).  Usually  larger  than  the  preceding,  they 
are  elongated  vertically  and  arrange  themselves  in  a  chain  parallel 
to  the  internal  jugular.  Some  of  these  glands  have  a  fairly  fixed 
position  ;  thus,  one  or  two  large  glands  are  constantly  found  imme- 
diately beneath  the  posterior  belly  of  the  digastric,  above  the  spot 
where  the  thyro-lingual-facial  trunk  opens  into  the  internal  jugular. 
We  shall  see  that  these  glands  represent  the  principal  terminus 
of  the  lymphatics  of  the  tongue  (vide  p.  279  and  Fig.  105).  Simi- 
larly, there  is  almost  always  a  faii^sized  gland  above  the  point 
where  the  omo-hyoid  crosses  the  internal  jugular.  Finally,  we 
often  find  glands  situated  'behind  the  internal  jugular,  between 
this  vessel  and  the  pre vertebral  muscles.  In  the  glands  of  the 
internal  group,  terminate,  with  or  without  previous  glandular 
interruption,  the  cutaneous  lymphatics  of  the  face,  and  the 
cervico-facial  portions  of  the  digestive  and  respiratory  passages. 

We  should  add  that  these  two  groups  are  united  by  a  great  many 
anastomoses,  and  that  their  subdivision,  which  makes  their  stud}r 
easier,  is  arranged  on  a  definite  plan,  to  which  we  must  draw 
attention. 

We  may  include  in  the  sterno-mastoid  group,  some  small  aberrant  glands 
placed  on  the  lateral  parts  of  the  larynx,  in  front  of  and  internal  to  the  large 
vessels.  These  inconstant  glands  are  usually  situated  beneath  the  great 
cornu  of  the  hyoid  bone.  We  usually  find  one  or  two  of  them  relatively 
superficial,  and  placed  on  the  omo-hyoid  a  little  below  the  insertion  of  this 
muscle  on  the  hyoid  bone  (vide  /,  Fig.  97).  At  the  same  level,  but  more 
deeply  placed,  that  is,  underneath  the  thyro-hyoid  muscle,  two  or  three 
minute  glands  are  also  found  lying  on  the  thyro-hyoid  membrane  or  on  the 
upper  part  of  the  alae  of  the  thyroid  cartilage.  These  glands,  not  mentioned 
by  Sappey,  have  been  well  shown  by  Bourgery  and  Jacob  (loc.  cit.,  plates  86 
and  91)  :  they  are  not  regional  glands,  but  simple  interrupting  glandular 
nodules  placed  in  the  course  of  the  visceral  afferents  of  the  sterno-mastoid 
glands  properly  so  called.  We  shall,  however,  have  occasion  later  on  to 
return  to  these  glandular  nodules,  when  studying  the  lymphatics  of  the 
tongue,  the  pharynx  and  the  larynx  (vide  p.  283  and  Fig.  110). 

Afferent  Vessels. — (A)  The  external  group  of  sub-sterno- 
mastoid  glands  receives  : 


LYMPHATICS    OF    THE    HEAD    AND    NECK  259 

1.  The    efferent    vessels    of    the    mastoid    glands,    sub-occipital 
glands,  and  some  vessels  coming  from  the  glands  placed  round  the 
external  jugular,  at  the  spot  where  the  latter  leaves  the  parotid. 

2.  A  large  collecting  trunk  which  comes  directly  from  the  occi- 
pital portion  of  the  hairy  scalp  (vide  p.  264). 

3.  Some    trunks    (inferior    trunks)    coming    from    the    auricle 
(vide  p.  264). 

4.  Some  cutaneous  and  muscular  vessels  from  the  upper  part 
of  the  neck. 

(B)  The  internal  group  at  first  receives  the  efferent  vessels  of 
the  retro-pharyngeal,  parotid  and  sub-parotid,  submaxillary,  and 
submental  glands,  the  superficial  and  deep  anterior  cervical 
chains,  and  the  recurrent  chain.  This  internal  group  constitutes 
therefore  a  second  glandular  relay  for  the  numerous  lymphatics 
which  are  tributaries  to  the  preceding  glands. 

Further,  this  group  receives  as  direct  afferents  : 

1.  The  majority  of  the  lymphatics  of  the  tongue  (vide  p.  278). 

2.  Certain  lymphatics  of    the  nasal  pharynx  and  the  whole    of 
the  lymphatics  of  the  middle  and  inferior  portions  of  the  larynx 
(p.  281). 

3.  The  lymphatics  of  the  vault  of  the  palate,  and  soft  palate. 

4.  The  lymphatics  of  the  cervical  portion  of  the  oesophagus. 

5.  The  lymphatics  of  the  nasal  fossae. 

6.  The  majority  of  lymphatics  of  the  larynx,  and  those  from 
the  cervical  portion  of  the  trachea. 

7.  The  lymphatics  of  the  thyroid  body. 

In  studying  the  arrangement  of  the  lymphatic  apparatus  of 
these  different  organs,  we  will  note  the  exact  position  of  the  glands 
of  the  sterno-mastoid  chain  in  which  their  absorbent  vessels  end. 

Efferent  Vessels.  — The  efferent  branches  of  the  internal 
jugular  chain  finally  resolve  themselves  into  one  or  two  large  vessels. 
The  latter  unite  with  the  efferent  vessels  of  the  subclavian  glands 
to  constitute  the  jugular  trunk.  On  the  right  side,  this  trunk 
terminates  in  the  junction  of  the  internal  jugular  and  subclavian 
vein,  at  the  apex  of  the  angle  which  is  open  externally,  and  which1 
is  formed  by  the  junction  of  these  two  vessels.  On  the  left,  it 
ends  in  the  terminal  bend  of  the  thoracic  duct ;  but  it  may  also 
end  directly  in  the  junction  of  the  two  veins.  (On  the  varieties 
of  the  terminal  lymphatic  trunks  at  the  base  of  the  neck,  vide 
pp.  291  and  292,  and  Fig.  112.) 

2.  THE   SUPRA-CLAVICULAR  GLANDS. — These  glands  occupy  the 


2CO  SPECIAL    STUDY    OF    THE    LYMPHATICS 

supra-clavicular  or  subclavian  triangle.  Their  relations  vary  in  the 
upper  and  lower  part  of  the  triangle. 

In  the  upper  part  of  the  triangle,  these  glands,  which  are  ex- 
tremely numerous,  form  a  layer  which  is  covered  by  the  superficial 
cervical  fascia,  and  rest  on  the  splenius,  the  levator  anguli 
scapulae,  and  the  scalene  muscles.  They  are  embedded  in  the 
mass  of  adipose  tissue  described  by  Merkel  under  the  name  of 
Fettpolster,  where  they  are  in  intimate  relation  with  the  branches 
of  the  cervical  plexus,  with  the  branch  to  the  trapezius  from  the 
third  and  fourth  cervical  nerves,  and  with  the  ascending  cervical 
artery. 

At  the  base  of  the  triangle,  this  group  to  some  extent  lies  on 
the  omo-hyoid  and  middle  layer  of  cervical  fascia.  The  majority 
of  glands  are  placed  in  front  of  this  layer  ;  here,  they  enter  into 
connexion  with  the  terminal  sub-fascial  portion  of  the  external 
jugular  and  the  descending  branches  of  the  cervical  plexus, 
where  the  latter  perforate  the  superficial  fascia  above  the  clavicle 
and  become  sub-cutaneous.  Others,  placed  more  deeply,  are 
situated  behind  the  omo-hyoid  and  the  middle  layer  of  fascia,  in 
front  of  the  third  portion  of  the  subclavian,  and  the  nerves  of  the 
brachial  plexus. 

The  supra-clavicular  glands  receive  as  afferent  vessels  : 

(1)  The  lymphatics  coming  from  the  posterior  part  of  the  hairy 
scalp,  from  the  skin,  and  from  the  muscles  of  the  neck. 

(2)  The  lymphatics  coming  from  the  integuments  of  the  pectoral 
region,  and  even  from  the  mammary  region  (vide  p.  216). 

(3)  The  cutaneous  lymphatics  of  the  arm,  satellites  of  the  cephalic 
vein,  which,  instead  of  reaching  the  sub-clavian  glands,  their  normal 
terminus,  pass  above  the  clavicle  and  empty  themselves  into  the 
supra-clavicular  glands  (p.  244). 

(4)  Some  of  the  afferentsof  the  axillary  glands  and  more  particu- 
larly the  afferents  of  these  glands  which  constitute  the  humeral 
chain  (vide  p.  239). 

On  the  other  hand,  these  glands  receive  no  vessels  coming  from 
the  mediastinal  glands.  Cases  of  adenitis  of  the  supra-clavicular 
glands  following  mediastinal  or  abdominal  neoplasms,  can  only  be 
explained  by  a  retrograde  thrombosis  of  the  afferent  vessels  of 
these  supra-clavicular  glands. 

As  we  have  seen,  the  efferent  vessels  of  the  supra-clavicular  glands 
unite  with  the  efferent  vessels  of  the  sterno-mastoid  glands  to 
constitute  a  common  trunk,  the  jugular  trunk.  On  the  right  side, 


LYMPHATICS    OF    THE    HEAD    AND    NECK          261 

this  trunk  terminates  in  the  junction  of  the  internal  jugular  and 
subclavian.  On  the  left,  it  usually  ends  in  the  terminal  bend  of 
the  thoracic  duct. 

Accessory  Chains. —  1.  The  external  jugular  chain  is  formed 
by  4  or  5  glands  placed  in  the  course  of  the  external  jugular  vein. 
Normally  this  chain  only  comprises  2  or  3  glands  situated  at  the 
spot  where  the  external  jugular  leaves  the  parotid.  These  glands 
rest  on  the  external  surface  of  the  sterno-mastoid  beneath  and  a 
little  behind  the  inferior  extremity  of  the  gland.  More  rarely, 
1  or  2  glands  are  found  on  the  middle  part  of  the  vein. 

These  glands  receive  their  afferent  vessels  from  the  auricle 
and  from  the  parotid  region.  Their  efferent  vessels  turn  round 
the  anterior  border  of  the  sterno-mastoid  and  end  in  the  superior 
glands  of  the  deep  cervical  chain  (vide  Fig.  97).  One  of  these 
efferents  may  follow  the  external  jugular  chain  and  pass  into  a 
supra-clavicular  gland. 

2.  The  superficial  anterior  cervical  chain  comprises  2  to  3  small 
inconstant  glands,  placed  in  the  course  of  the  anterior  jugular  vein. 

3.  Under  the  name  anterior  deep  cervical  chain,  we  may  describe 
the   collection  of   glands   which   are   found   below   the   sub-hyoid 
muscles,  immediately  in  front  of  the  larynx  and  trachea. 

These  glands  may  be  divided  into  three  distinct  masses  :  the 
prae-laryngeal,  the  prae- thyroid,  and  prae-tracheal. 

(a)  The  prae-laryngeal  mass  comprises  1  to  3  glands.  Engel 
(Compendium  der  Topographischen  Anatomic,  Wien,  1859,  p.  182) 
was  the  first  to  point  out  the  presence  of  a  gland  in  front  of  the 
larynx.  Since  then,  one  of  the  present  writers  has  studied  this 
glandular  mass,  and  has  endeavoured  to  establish  its  frequency 
and  usual  arrangement.  As  a  matter  of  fact,  this  glandular  group 
is  inconstant.  Prae-laryngeal  glands  are  found  in  only  49 
out  of  100  cases  (Poirier).  Most  frequently,  only  a  single  gland 
is  present,  which  is  situated  in  the  middle  of  the  V-shaped  space 
bounded  by  the  two  crico-thyroids.  Sometimes,  this  gland  is 
hidden  under  the  edge  of  one  of  these  muscles.  In  some  cases, 
there  is  a  second  gland  subjacent  to  the  preceding  and  occupying 
the  summit  of  the  V-shaped  space.  Again,  we  may  find,  though 
more  rarely,  another  gland  in  front  of  the  cricoid,  above  the 
isthmus  of  the  thyroid  body  (Most,  Roubaud). 

These  prae-laryngeal  'glands  receive,  as  afferents,  some  of  the 
lymphatics  which  constitute  the  middle  lymphatic  pedicle  of  the 
larynx  (vide  pp.  287  and  288).  Their  efferent  vessels  pass  either  to  the 

Q* 


262  SPECIAL    STUDY    OF    THE    LYMPHATICS 

prae-tracheal  glands,  or  to  the  inferior  glands  of  the  sterno-mastoid 
chain.  It  is  more  rare  to  see  these  vessels  take  an  ascending  course 
and  unite  with  the  vessels  which  constitute  the  superior  lymphatic 
pedicle  of  the  larynx. 

(b)  The  prae-thyroid  mass  has  been  figured  by  Bourgery   (loc. 
cit.,  plates   97  and  91).     We  regard  its  presence  as  exceptional. 

(c)  The    prae-tracheal   mass   is    much    more    frequently   present. 
It   comprises   one   or   several  glands.      These   are   however,    most 
frequently  very  small,  and  only  visible  in  specimens  injected  with 
coloured  material. 

The  prae-tracheal  glands  receive  as  afferents,  the  lymphatics  which 
come  from  the  thyroid  body  and  some  of  the  efferents  of  the  prae- 
laryngeal  glands.  Their  efferent  vessels  run  downwards  and  out- 
wards and  pass  into  the  inferior  glands  of  the  sterno-mastoid  chain. 

These  three  glandular  masses  are  as  inconstant  in  their  presence 
as  they  are  variable  in  their  arrangement,  and  we  are  inclined  to 
regard  their  constituent  glands,  not  as  true  regional  glands  of  the 
larynx  or  thyroid  body,  but  as  simple  interrupting  glandular 
nodules,  placed  in  the  course  of  the  lymphatics  coming  from  these 
two  organs. 

4.  The  recurrent  chain  comprises  3  to  6  minute  glands,  situated 
on  the  lateral  parts  of  the  oesophagus  and  trachea,  along  the  re- 
current laryngeal  nerves.  Unless  their  afferent  vessels  are  in- 
jected, these  glands,  which  are  always  very  small,  may  pass  un- 
recognized. Inferiorly,  this  chain  is  continuous,  without  clear 
line  of  demarcation,  with  the  praetracheo-bronchial  groups. 

The  glands  of  the  recurrent  chain  receive  as  afferents,  the  lym- 
phatics of  the  inferior  pedicle  of  the  larynx  (vide  p.  288),  and 
the  vessels  coming  from  the  cervical  portion  of  the  trachea  and 
oesophagus,  and  some  of  the  lymphatics  of  the  thyroid  body.  Con- 
trary to  what  we  should  at  first  expect,  the  efferent  vessels  of  this 
chain  do  not  end  in  the  mediastinal  glands  ;  but  incline  outwards, 
and  pass  either  in  front  of  or  behind  the  vessels  and  nerves  of  the 
neck,  terminating  either  in  the  inferior  glands  of  the  sterno- 
mastoid  chain,  or  in  the  supra-clavicular  glands. 

Gouguenheim  and  Leval-Piquechef,  who  have  given  a  detailed  account 
of  this  glandular  chain,  have  described  it  as  formed  of  three  masses,  viz. 
a  superior,  middle,  and  inferior.  We  have  most  frequently  seen  these  glands 
arranged  in  a  continuous  chain,  and  this  division  into  three  masses  does  not 
seem  to  us  to  be  justified.  On  the  other  hand,  these  authors  have  rightly 
drawn  attention  to  the  importance  of  this  glandular  chain  in  explaining 
certain  cases  of  paralysis  of  the  recurrent  laryngeal  nerve  by  compression. 


LYMPHATICS    OF    THE    HEAD    AND    NECK          263 

Vide.  Gouguenheim  et  Leval-Piquechef.  Annales  des  maladies  de  Voreille 
et  du  larynx,  1884,  p.  15. 

§  2.  LYMPHATIC  VESSELS  OF  THE  HEAD  AND  NECK. 

WE  will  study  in  turn  :  (1)  the  lymphatics  of  the  cranial  region  ; 
(2)  the  lymphatics  of  the  face  ;  (3)  the  lymphatics  of  the  facial  and 
cervical  segments  of  the  digestive  passages  ;  (4)  the  lymphatics  of 
the  corresponding  portion  of  the  respiratory  passages. 

1.    LYMPHATIC  VESSELS   OF   THE  CRANIAL  REGION. 

The  study  of  the  lymphatic  vessels  of  the  cranial  region  resolves 
itself  into  that  of  the  lymphatics  of  the  corresponding  integuments. 
The  vessels  of  the  subcutaneous  soft  parts  in  fact  pursue  a  course 
exactly  similar  to  that  of  the  lymphatics  of  the  skin.  As  regards 
the  intra-cranial  organs  (the  encephalon  and  its  membranes),  it  is 
now  generally  agreed  that  they  are  without  lymphatics. 

Fohmann,  Mascagni,  Fr.  Arnold  have,  however,  described  and  figured 
meningeal  lymphatics.  They  have  clearly  been  deceived.  If  the  nervous 
centres  contain  spaces  which  are  to  some  extent  comparable  to  lymphatic 
channels,  they  do  not  possess  "  lymphatic  vessels  "  in  the  proper  sense  of 
the  word.  We  should  further  add  that  these  spaces  are  usually  regarded 
as  absolutely  independent  of  the  lymphatic  system. 

On  the  question  of  the  lymphatics  of  the  nervous  centres,  vide  vol.  iii. 
pp.  95  and  122.1 

The  lymphatics  of  the  integuments  of  the  cranial  region  arise 
from  a  network  with  very  close  meshes.  This  network  is  most 
dense  near  the  middle  line  and  in  the  region  of  the  vertex.  As  we 
approach  the  periphery  of  the  hairy  scalp,  the  meshes  become 
larger  and  the  network  scantier,  without  however  ceasing  to  be 
continuous. 

The  trunks  arising  from  this  network  may  be  divided  into  anterior 
or  frontal,  lateral  or  parietal,  posterior  or  occipital. 

(1)  The  frontal  are   10  to   12  in  number.     They  run  obliquely 
downwards  and  backwards,  and  approach  more  nearly  to  the  hori- 
zontal as  they  go  lower.     Those  situated  nearest  the  orbital  arch 
take  their  origin  from  the  skin  over  the  eyebrow  and  root  of  the 
nose  (Kuttner).     All  terminate  in  the  parotid  glands. 

(2)  The  parietal  or  temporal  are  divisible  into  two  groups  :    viz. 
anterior   and   posterior.     The    anterior   trunks   which    vary   from 
3  to  5  in  number,  pass  into  the  parotid  glands.     The  posterior 
trunks  are  usually  more  numerous  and  end  in  the  mastoid  glands. 

1  Treatise  of  Hitman  Anatomy,  Poirier  and  Charpy. 


264 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


(3)  The  occipital  are  also  divided  into  two  groups.  The  external 
trunks,  which  number  5  or  6,  converge  "  to  form  a  very  remark- 
able single  and  constant  trunk.  This  trunk  is  directed  almost 
vertically  downwards,  is  then  attached  to  the  posterior  border  of 


^.  ad.  nicib.  del> . 


FIG.  98. — Lymphatics  of  the  head  and  neck:  right  lymphatic  duct  (after  Sappey). 
1,  1.  Lymphatic  vessels  which  pass  into  the  parotid  glands.  2,  2.  Inferior  frontal  lym- 
phatics. 3,  3.  Superior  frontal  lymphatics.  4,  4.  Parietal  lymphatic  vessels  ;  they  descend 
vertically,  and  anastomosing  with  the  neighbouring  vessels,  terminate  in  the  mastoid  glands. 
5,  5.  Origin  of  these  vessels.  6,  6.  Anterior  sub-occipital  vessels  converging  to  form  a 
single  trunk  which,  after  a  long  course,  ends  in  one  of  the  lowest  of  the  cervical  glands. 
7.  Trunk  resulting  from  the  convergence  of  these  vessels.  8.  Gland  in  which  this  trunk 
terminates.  9,  9.  Posterior  sub-occipital  vessels  ending  in  two  glands  situated  on  the 
anterior  border  of  the  trapezius.  10,  10.  These  two  glands.  11.  Large  horizontal  trunk 
coming  from  the  higher  of  these  glands,  running  underneath  the  splenius,  and  ending  in  the 
sub-mastoid  glands.  12.  Vessels  which  take  origin  from  the  superior  mastoid  glands  and 
which  traverse  the  sterno -mastoid  and  terminate  in  the  glands  situated  beneath  this  muscle. 
13.  Parotid  glands.  14,  14.  Cervical  glands,  and  afferent  vessels  of  those  glands.  15,  15. 
Lymphatic  vessels  which  take  origin  from  the  integuments  of  the  nose.  16,  16.  Lymphatic 
vessels  of  the  lips.  17.  Sub-maxillary  glands.  18.  Lymphatic  vessels  coming  from  the 
middle  part  of  the  lower  lip.  19.  Supra-hyoid  gland  in  which  this  vessel  terminates.  20. 
Bight  lymphatic  duct. 


LYMPHATICS  OF  THE  HEAD  AND  NECK 


265 


the  sterno-mastoid,  under  which  it  passes  and  terminates  in  one  of 
the  external  glands  of  the  sterno-mastoid  group.  Sometimes  it 
descends  into  the  subclavian  triangle,  while  at  others  it  does  not 
pass  beyond  the  middle  line  of  the  neck  "  (Sappey).  The  internal 
trunks  pass  into  the  occipital  glands.  They  may  also  pass  into 
the  aberrant  glands  of  the  neck,  to  the  existence  of  Avhich  we 
have  drawn  attention  (p.  248). 

2.  LYMPHATIC  VESSELS  OF  THE  FACE. 

As  we  shall  have  to  study  separately  the  lymphatics  of  the  mucous 
membranes  of  the  different  cavities  of  the  face,  we  will  here  con- 
sider only  the  cutaneous  lymphatics. 

Very  thin,  and  difficult  to  inject,  these  vessels  terminate  in  the 
parotid,  submaxillary  and  submental  glands.  Though  their  net- 
work of  origin  is  absolutely  continuous  over  the  entire  face,  the 
lymphatics  of  certain  regions,  on  account  of  their  practical  import- 
ance, merit  a  special  description. 

LYMPHATICS  OF  THE  EYELID  AND  CONJUNCTIVA. — These  vessels 
take  origin  from  a 
network  which 
occupies  the  entire 
cutaneous  surface 
of  the  eyelids  and 
the  whole  of  the 
conjunctiva.  At  the 
free  border  of  the 
lids  this  network 
becomes  extremely 
close.  The  terminal 
trunks  form  two 
distinct  groups. 

Some  of  them,  2 
or  3  in  number, 
run  inwards  and 
terminate  in  a 
median  or  para- 
median  trunk  which 

springs      from      the  FIG.  99.— Lymphatics  of  the  neck  (after  Kiittner). 

inter-SUDerciliarV  "'    ^arotit^    gland,      b,    I.    Glands    of  the  external  jugular 

*       chain,     c,  c.  Facial  gland.     (/.  Submaxillary  gland,     c.  Gland 
Space,    and    ends    in      of  the  internal  jugular  chain. 

the       submaxillary 

glands.     Others,    which    are    much    more    important,   and    wliich 


260  SPECIAL    STUDY    OF    THE    LYMPHATICS 

drain  about  the  outer  three-fourths  of  the  two  eyelids,  run 
obliquely  downwards  and  backwards  and  pass  into  the  parotid 
glands. 

LYMPHATICS  OF  THE  NOSE. — The  lymphatic  vessels  of  the  integu- 
ments of  the  nose,  recently  well  studied  by  Kiittner,  arise  from  a 
network  with  somewhat  large  meshes  at  the  root  of  the  organ,  but 
which,  on  the  contrary,  is  very  dense  over  the  alae  and  lobule. 

Injections  easily  pass  beyond  the  middle  line,  and  a  lateral 
puncture  may  inject  the  collecting  trunks  of  the  opposite  side. 
This  cutaneous  network  is  continuous  with  the  lymphatics  of  the 
vestibule  of  the  nasal  fossae  and  through  them  with  the  lymphatics 
of  the  mucous  membrane.  Kiittner,  who  lays  stress  on  this  com- 
munication, was  able,  by  puncturing  the  integuments,  to  distend 
the  mucous  lymphatics  and  to  follow  their  collecting  trunks  as 
far  as  the  dorsal  surface  of  the  soft  palate  ;  but  he  makes  no  definite 
statements  as  to  the  arrangement  of  the  anastomoses. 

The  trunks  arising  from  the  cutaneous  network  may  be  classified 
into  three  groups  (Kiittner)  (vide  Fig.  99). 

(a)  The  lymphatics  of  the  first  group  arise  from  the  root  of  the 
nose,  pass  above  the  upper  eyelid,  and,  running  along  the  upper 
border  of  the  orbit,  then  curve  downwards  and  terminate  in  the 
superior  parotid  glands. 

(b)  The  lymphatics   of  the   second  group   are   usually  three   in 
number.     They  arise  from  the  root  and  sides  of  the  nose  ;    they  are 
at  first  directed  immediately  backwards,  at  the  level  of  the  adherent 
border  of  the  lower  lid,  they  then  run  more  or  less  vertically  down- 
wards, and  passing  in  front  of  the  parotid,  which  they  penetrate 
near  its  lower  extremity,  terminate  in  the  parotid  glands  situated 
there. 

(c)  The  third  group  is  the  most  important.     It  comprises  6  to 
10  trunks  which  spring  from  the  entire  extent  of  the  cutaneous 
network.     They  run  with  the  facial  vessels  and  terminate  in  the 
sub-maxillary  glands.     Some  of  them  may  be  interrupted  in  one 
of  the  facial  glands  (vide  p.  253). 

BIBLIOGRAPHY. — KUTTNER.  Uber  die  Lymphgefasse  cler  aussereii  Xase 
urid  die  zugehorigeii  Wangenlymphdriiseii  in  ihre  Beziehuiig  zur  cler  Ver- 
breitung  des  Xasenkrebs.  Beitrage  z.  klin.  Chit:,  1899,  XXV,  p.  33. 

LYMPHATICS  OF  THE  LIPS. — The  lymphatics  of  the  lips  arise  from 
two  networks,  one  cutaneous,  and  the  other  mucous,  which  are 
in  continuity  with  each  other  at  the  free  border.  From  these 
two  networks  run  the  collecting  trunks  which  receive  in  their 


LYMPHATICS    OF    THE    HEAD    AND    NECK 


267 


N 


FIG.    100. — Lymphatics  of  the   lower    lip 

(after  Doreiidorf). 

a.  Trunk  ending  in  the  submaxillary 
glands.  l>.  Trunk  oncling  in  the  glands  of  the 
internal  jugular  chain  (rtbnormal). 


course  the  lymphatic  vessels  of  the  muscular  coat  which  are  much 

less  developed. 

In    the    upper    lip    there   are 

two    sub-mucous,     and    two  or 

three    sub-cutaneous    collecting 

trunks  on  either  side.      All  pass 

to  the  sub-maxillary  glands  and 

more   especially   to    the   middle 

gland,  placed  at  the  spot  where 

the     facial    artery    crosses    the 

inferior   border    of  the  maxilla. 

One    of   these  collecting  trunks 

may     open     into     one    of   the 

trunks   coming  from   the   lower 

lip,  or  end  in  one  of  the  glands 

placed  round  the  external  jugu- 
lar at  its  exit  from  the  parotid 

(Dorendorf)  (vide  Fig.  101). 

In  the  lower  lip,  the  subcutaneous  vessels  are  from  2  to  4  in 

number  on  either  side.     The  trunks  coming  from  the  middle  portion 

of  the  lip  end  in  the  submental  glands.     Those  which  spring  from 

the  neighbourhood  of  the  commissure  reach  the  most  anterior  of 

the    submaxillary    glands.     The    submucous    vessels,    2    or    3    in 

number  on  each  half  of  the 
lip,  run  downwards  and  out- 
wards, and  embracing  the 
facial  artery,  terminate  in 
the  submaxillary  glands.  As 
Sappey  long  since  remarked, 
it  is  exceptional  to  see  any  of 
these  vessels  ending  in  the 
submental  glands.  Doren- 
dorf has  seen  lymphatics 
springing  from  the  gingivo- 
labial  groove,  sink  into  the 
dental  canal. 

To  sum  up,  the  submaxil- 
lary and  submental  glands 
represent  the  first  glandular 

relay  of  the  lymphatics  of  the  lips  ;    it  is  only  exceptionally  that 
we  see  one  of  these  vessels  pass  by  this  first  station  and  directly 


FK;    101.— Lymphatics     of    the    lips    (after 

Dorendorf). 

a.  Trunk  ending  in  the  submaxillary  glands. 
b.  Collecting  trunk  of  the  upper  lip  terminating 
in  a  gland  of  the  external  jugular  chain. 


268 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


reach   the    deep   cervical  glands.     Dorendorf   lias   pointed  out  an 

example  of  this  arrangement  (vide  Fig.  102). 

The  collecting  trunks  of  the  upper  lip  neither  cross  nor  anastomose 

with  one  another.  The  same 
remark  applies  to  the  sub- 
mucous  collectors  of  the  lower 
lip.  On  the  other  hand,  the 
right  and  left  subcutaneous 
trunks  of  this  lip  frequently 
cross  one  another  on  the  middle 
line,  or  present  anastomoses 
which  are  practically  equiva- 
lent to  inter-crossing  (vide  Fig. 
100).  In  the  case  of  cancers 
of  the  lower  lip,  the  submental 
and  the  submaxillary  glands  of 
both  sides  should  be  regarded 
as  liable  to  become  infected. 


FIG.  102. — Lymphatics    of   the   lips    (after 

Dorendorf). 

a.  Collectors  of  the  upper  lip  ending  in 
the  submaxillary  glands.  b.  Collectors  of 
the  lower  lip  ending  in  the  same  glands.  c. 
Vessel  passing  directly  to  a  gland  of  the 
internal  jugular  chain. 


BIBLIOGRAPHY.  —  DOREX- 
DORF.  Ueber  die  Lymphgefasse  mid 

Lymphdriisen  der  Lippe  mit.  Bezielmng  .  .  .  etc.  Intermit.  Monatschr,  /. 
Anat.  u.  PhysioL,  1900,  XVil,  p.  201. — STIEDA.  Zur  Lymphdriisen-Exstirpa- 
tioii  beim  Unterlippenkrebs,  Arch.  f.  klin.  Chirurgie,  1901,  p.  613. 

LYMPHATICS  OF  THE  AURICLE  AND  EXTERNAL  AUDITORY 
MEATUS. — The  lymphatics  of  the  auricle  and  external  auditory 
meatus  take  their  origin  from  a  cutaneous  network  the  injection 
of  which,  at  least  in  the  infant,  we  have  always  found  very 
easy.  The  collecting  trunks  coming  from  this  network  may  be 
divided  into  three  groups  :  posterior,  anterior  and  inferior. 

1.  The  posterior  group  has  for  its  territory  of  origin  a  portion 
of     the     external     surface     of     the     auricle     (viz.      helix,     anti- 
helix,  and   the   fossa   between   them),   the   whole   of   the  internal 
surface   and  posterior  portion   of   the   external   auditory   meatus. 
Numbering    from  6  to   12,  they  end  for  the  greater  part  in  the 
mastoid  glands.     Some,  however,  avoid  this  first  glandular  relay 
and  join  the  efferent  vessels  of  the  retro-auricular  glands,  and  pass, 
with  them  into  the  glands  placed  beneath  the  sterno-mastoid.     In 
their  course,  they  perforate  the  superior  insertions  of  this  muscle 
or  turn  round  its  anterior  border. 

2.  The  inferior  group  includes  a  very  variable  number  of  trunks 
coming  from  the   lobule,  from  the  adjacent  portions  of  the  auricle 


LYMPHATICS  OF  THE  HEAD  AND  NECK 


269 


and  from  the  lower  wall  of  the  external  auditory  meatus.  Some  of 
these  trunks 
pass  into  the 
glands  placed 
on  the  course 
of  the  exter- 
nal jugular 
vein,  at  its 
exit  from 
the  parotid. 
Others  pass 
into  the  sub- 
sterno  -  mas  - 
told  glands. 

3.  The  an- 
terior group 
is  formed  by 
4  to  6  trunks 
which  drain 

Fro.    103. — Lymphatics  of  the  vestibule  ot    the  auricle  (internal 
the  lymph  surface). 

fro  111        the  G-  Collecting  trunks  of  the  auricle,     h.  Mastohl  glands,     c.  Sterno- 

,  ,          nmstoid  gland  (external    croup),      d.  Gland  of   the  external  jugular 

concha     and 

the    anterior 

wall    of    the 

meatus.     These    vessels   pass    into   the   parotid   glands  and  more 

particularly  into  the  constant  gland  situated  immediately  in  front 

of  the  tragus. 

BIBLIOGRAPHY. — V.   STAHR  (H.)  Veber  den  Lymphapparat  des  aussereii 
Ohrs.  An.  Anz.,  1899,  p.  381. 


\ 


chain,  e.  Sterno-mastoid  gland  (internal  group,  internal  jugular 
chain).  /.  Sub-hyoid  aberrant,  gland,  placed  in  the  course  of  the- 
efferent  vessels  of  the  submental  glands 


3.    LYMPHATICS    OF    THE    FACIO-CERVICAL    PORTION 
DIGESTIVE    PASSAGES. 


OF  THE 


LYMPHATICS  OF  THE  GUMS. — The  mucous  membrane  of  the  gums 
is  covered  by  a  network  with  extremely  closely  set  meshes  ;  its 
injection  is  nevertheless  difficult.  The  collecting  trunks  of  this 
network  arise  from  the  internal  surface  of  the  gums,  then  run  out- 
wards passing  between  the  teeth  ;  their  number  varies  from  14 
to  17  (Sappey).  Having  arrived  on  the  outer  side  of  the  alveolar 
margins,  they  terminate  in  a  large  semicircular  trunk  which  runs 
along  the  margins  from  before  backwards,  progressively  increasing 
in  size.  At  the  level  of  the  last  molars,  this  trunk  sinks  into  the 


270  SPECIAL    STUDY    OF    THE    LYMPHATICS 

cheek  and  ends  in  the  hindermost  of  the  submaxillary  glands 
(Sappey). 

The  lymphatic  network  of  the  gums  is  continuous,  externally, 
with  that  of  the  mucuous  surface  of  the  lips  and  cheeks,  and  inter- 
nally, with  the  network  of  the  mucous  membrane  of  the  floor  of  the 
mouth  in  the  case  of  the  mandible,  and  with  that  of  the  palatine 
vault  in  the  case  of  the  maxilla. 

LYMPHATICS  OF  THE  TEETH. — The  presence  of  lymphatic  vessels 
in  the  dental  pulp  has  not  yet  been  demonstrated.  Sappey  vainly 
tried  to  inject  them.  Other  authors,  however,  placed  the  existence 
of  these  vessels  beyond  a  doubt  (Arkowy,  Odenthal,  Wangermann, 
etc.).  Their  opinions,  however,  rest  on  a  priori  conceptions  or  on 
pathological  deductions,  but  not  upon  direct  observations. 

Bodecker  in  1896  observed  in  the  dental  pulp,  vessels  with  the 
histological  characteristics  of  lymphatic  capillaries.  More  recently, 
Partsch  and  Korner  have  again  tried  to  solve  the  question.  Korner, 
using  Gerota's  method,  attempted  to  inject  the  lymphatics  of  the 
pulp  after  exposing  it.  He  failed  in  all  his  attempts  ;  the  mass 
passed  exclusively  into  the  blood  vessels.  On  the  other  hand, 
when  coloured  particles  were  simply  deposited  in  the  dental  pulp 
of  young  dogs,  these  particles  were  again  found  after  some  time 
in  the  submaxillary  glands.  But,  though  this  observation  may  show 
that  the  inter-fascicular  spaces  of  the  pulp  are  in  direct  relation 
with  the  lymphatic  system,  it  is  insufficient  to  enable  us  to  affirm 
the  existence  of  lymphatic  vessels  in  this  pulp. 

In  short,  these  researches  are  incomplete.  Korner  ought  to  have 
examined,  not  only  the  submaxillary  glands,  but  also  the  parotid 
glands.  The  lymphatics  of  the  teeth,  if  such  exist,  would  naturally 
pass  into  the  parotid  glands,  following  the  dental  vessels. 

Of  the  relationship  between  dental  lesions  and  certain  affections,  acute  or 
chronic,  of  the  submaxillary  glands,  there  can  be  no  doubt ;  but  the  existence  of 
lymphatic  vessels  in  the  pulp  is  not  necessary  to  explain  them.  The  lesions 
of  the  alveolar-dental  periosteum  and  the  adjacent  portion  of  the  gum, 
which  frequently,  if  not  invariably,  follow  dental  caries,  are  sufficient  to  ex- 
plain the  inflammation  of  the  submaxillary  glands. 

BIBLIOGRAPHY. — Ba?decker.  Die  Anatomie  und  Pathologic  der  Zahne  (Wieii 
u.  Leipzig,  Wilhem  Braumuller,  1896). — Koerner.  Ueber  die  Beziehungeii 
cler  Erkrankungen  der  Zahne  zu  den  chronischen  Schwellunge  nder  regionaren. 
Druse,  Berlin,  1897.-Ollendorn°.  Ueber  den  Zusammenh  ang  derSchwellungen 
der  regionaren  Lymphdrusen  .  .  .  etc.  Deutsche  Monatschrift  fur  Zahn- 
heilkunde,  juin  1898. — Partsch.  Odontolocjische  Blatter,  1899. 

LYMPHATICS   or  THE   TONGUE. — On   account  of  their  practical 


LYMPHATICS  OF  THE  HEAD  AND  NECK 


271 


importance,  we  will  devote  more  time  to  the  consideration  of  the 
lymphatics  of  the  tongue. 

I.  NETWORKS  OF  ORIGIN. — Some  of  the  lymphatics  of  the  tongue 
come  from  the  mucous  membrane  (superficial  lymphatics),  others 
from  the  muscles  (deep  lymphatics). 


FIG.  104. — Lymphatic  vessels  of  the  dorsal  surface  of  the  tongue  (after  Sappcy). 
1,  1.  Lymphatic  network  of  the  anterior  third  of  the  tongue,  formed  of  radicles  of  extreme 
tenuity.  2,  2.  Lymphatic  network  of  the  middle  part,  formed  by  larger  radicles,  especially 
on  the  borders  of  the  tongue  ,  converging  from  behind  forwards,  and  from  without 
inwards,  and  following  the  same  course  as  the  papillary  grooves.  3,  3.  Network 
which  corresponds  to  the  caliciform  papillae  :  it  is  composed  of  much  larger  truncules 
which  creep  round  and  encircle  these  papillae.  4,  4.  Lymphatic  trunks  which  arise  from 
the  lateral  parts  of  this  network.  5,  5.  One  of  these  trunks  which  runs  external  to  the 
tonsils,  and  passes  into  the  middle  glands  of  the  neck.  6,  6.  Anterior  lymphatic  glands 
of  the  soft  palate  anastomosing  with  the  lateral  trunks  of  the  dorsal  surface  and  forming 
with  them  a  small  yjlexus.  7,  7.  Another  lateral  trunk  which  passes  internal  to  the 
corresponding  tonsil.  8,  8.  Trunks  which  run  from  the  middle  part  of  this  plexus. 
9,  9.  Other  smaller  trunks,  stretching  from  the  preceding,  and  disappearing  like  them 
through  the  walls  of  the  pharynx. 


272  SPECIAL    STUDY    OF    THE    LYMPHATICS 

1.  Superficial  lymphatics. — The  network  in  the  mucous 
membrane  extends  uninterruptedly  over  the  whole  of  the  lingual 
mucous  membrane  ;  at  the  edges  of  the  latter,  it  is  continuous 
without  a  clear  line  of  demarcation  with  the  homologous  network 
of  the  adjacent  mucous  membrane.  Sappey  has  given  a  description 
of  this  mucous  membrane  network  which  has  become  classical. 

';  When,  after  the  injection  of  the  lymphatic  vessels  of  the  entire 
free  surface  of  the  mucous  membrane  of  the  tongue,  the  network 
which  covers  it  is  examined,  we  notice  that  it  differs  somewhat 
considerably  on  the  anterior,  middle,  and  posterior  third  of  the  dorsal 
surface  and  on  the  edges  of  its  inferior  surface.  On  the  anterior  third 
of  the  dorsal  surface,  the  network  is  remarkable  for  its  uniform 
aspect,  for  the  extreme  tenuity  of  the  radicles  which  go  to  form  it, 
and  the  extreme  smallness  of  its  meshes. 

"  In  the  middle  third  it  is  more  developed  and  presents  a  very 
different  appearance.  The  papillae  of  the  third  order  are  arranged 
on  this  portion  of  the  dorsal  surface  in  linear  series  and  parallel  to 
the  double  row  of  caliciform  papillae.  We  may  see  on  either  side 
of  the  median  furrow,  the  network  resolving  itself  into  small  parallel 
ridges  like  the  nerves  of  a  leaf,  and  having  this  furrow  for  their 
common  centre  which  binds  them  together  like  the  stem  of  a  pen 
into  which  the  feathers  are  inserted.  The  nearer  we  approach  the 
caliciform  papillae,  the  more  important  does  this  network  become. 
Even  in  front  of  the  caliciform  papillae,  the  sub-papillary 
truncules  are  of  considerable  calibre,  and  are  easily  distinguish- 
able to  the  naked  eye.  Passing  between  these  papillae,  the}r 
deflect  and  turn  round  them,  some  running  on  their  inner  and 
some  on  their  outer  aspect,  anastomosing  with  each  other  all 
the  way.  Having  arrived  at  the  back  of  the  caliciform  papillae, 
they  receive  another  multitude  of  branches  and  branchlets  coming 
from  the  conical  papillae  which  may  be  observed  on  their  posterior 
part,  to  the  extent  of  half  a  centimetre,  then  they  converge  and 
give  origin  to  6  or  8  large  trunks.  In  the  posterior  third,  which  is 
vertical,  only  papillae  of  the  fourth  order,  or  extremely  small 
papillae  of  hemispherical  shape,  exist.  The  lymphatic  radicles 
which  run  from  them  are  very  numerous  and  pass  almost  at  once 
into  the  subjacent  trunks. 

"  At  the  borders  of  the  tongue,  the  mucous  membrane  has  as  its 
own  special  attributes,  folds  perpendicular  in  direction,  surmounted 
by  tubercles  or  simple  papillae,  and  separated  by  well  marked 
furrows.  All  these  folds  are  the  starting-point  of  innumerable 


LYMPHATICS    OF    THE    HEAD    AND    NECK  273 

lymphatic  branchlets,  which  form  under  the  base  of  the  papillae, 
an  extremely  rich  network  continuous  above  with  that  on  the  dorsal 
surface  and  below  with  that  on  the  inferior  surface.  This  latter 
differs  but  slightly  from  that  on  the  dorsal  surface,  and  is  especially 
characterized  by  the  transverse  direction  of  its  meshes  "  (Sappev). 

All  the  mucous  lymphatics  of  the  body 1  of  the  tongue  communicate 
with  one  another,  and,  in  some  subjects,  a  single  puncture  suffices 
to  inject  them  all.  On  the  other  hand,  the  lymphatics  of  the  base 
of  the  tongue  are  to  some  extent  independent,  and  require  for  their 
injection  one  or  several  special  punctures  (Kiittner). 

Is  this  independence  due  to  the  embryologies!  difference  in  origin 
between  the  body  and  the  base  ?  We  should  add  that  the  injection 
always  passes  beyond  the  middle  line  without  difficulty,  and  that 
a  unilateral  puncture  may  inject  the  collecting  trunks  of  both 
sides. 

2.  Deep  Lymphatics. — It  is  almost  impossible  to  demonstrate 
the  muscular  lymphatics  by  injection  with  mercury.  They  may, 
on  the  contrary,  be  injected  by  Gerota's  method  without  much 
difficulty.  By  means  of  this  process,  we  have  been  able  to  satisfy 
ourselves,  as  Kiittner  has  done,  that  their  collecting  trunks,  after 
a  short  course,  unite  with  the  efferents  of  the  mucous  membrane 
network. 

II.  COLLECTING  TRUNKS. — From  these  networks  of  origin  arise 
a  considerable  number  of  collectors,  which  may  be  divided  into 
four  groups— 

1.  An  anterior  or  apical  group. 

2.  A  lateral  or  marginal  group. 

3.  A  posterior  or  basal  group. 

4.  A  median  or  central  group. 

(1)  Apical  Trunks. — We  will  reserve  the  name  of  apical  trunks 
for  those  collectors  which  arise  from  the  extreme  point  of  the  tongue. 
They  are  usually  two  in  number  on  each  side  (a  and  b,  Fig.  105), 
and  are  almost  always  very  fine  and  run  downwards  and  forwards, 
in  or  at  the  sides  of  the  fraenum.  They  thus  corne  in  contact  with 
the  posterior  surface  of  the  mandible,  where  they  separate.  One 
(6),  after  being  to  some  extent  bent  on  the  bone,  runs  downwards 
and  backwards,  passes  between  the  genio-hyoglossus  and  the 
mylo-hyoid,  then  crosses  the  great  cornu  of  the  hyoid  bone  behind 
the  pulley  of  the  digastric.  It  then  descends  into  the  sub-hyoid 
region,  and  running  along  the  external  border  of  the  omo-hyoid, 

1  Vide  vol.  iv.,  p.  97,   Treatise  of  Human  Anatomy.      Poirier  and  Charpy. 

R 


274 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


empties  itself  into   a  gland  which  rests  on  the  internal  jugular 
immediately  above  the  point  where  this  vessel  is  crossed  by  the 


FIG.  105. — Lymphatics  of  the  tongue,  anterior  view  (Poirier). 

a,  6.  Apical  trunks,  c.  Marginal  trunks,  d.  Marginal  collecting  trunks  running  with 
tho  hypoglossal  nerve  over  the  external  surface  of  the  hyoglossus.  e.  Interrupting  nodule 
placed  in  the  course  of  these  vessels.  /,  y.  Basal  trunks,  h.  Principal  gland,  i.  Supra- 
omo-hyoid  gland.  /.  Submental  gland,  k.  Central  trunk  ending  in  the  supra-omo-hyoid 
gland.  1.  Interrupting  nodule.  m.  Marginal  trunk,  ending  in  the  supra-omo-hyoid 
gland. 

omo-hyoid.  The  other  trunk  (a)  perforates  the  mylo-hyoid  and 
terminates  in  the  supra-hyoid  median  glands.  It  usually  ends  in 
the  gland  nearest  to  the  symphysis. 

This  termination  of  the  lymphatics  of  the  apex  in  the  submental  glands 
is  not  mentioned  in  our  older  works.  Mascagni  makes  no  mention  of  it, 
Sappey  figures  it  (loc.  cit.,  plate  21,  Fig.  2),  but  does  not  describe  it  in  his  text. 


LYMPHATICS    OF   THE    HEAD    AND    NECK  275 

In  his  monograph  on  the  lymphatics  of  the  tongue,  Kiittiier  declares  he  has 
never  seen  any  of  the  lingual  lymphatics  terminate  in  the  submental  glands. 
However,  there  is  no  doubt  on  this  point. 

In  twenty  tongues,  for  the  greater  part  taken  from  the  new-born  or  very 
young  subjects,  injection  of  mercury  has  five  times  demonstrated  this 
termination  (Poirier,  vol.  v.,  note  on  p.  127).  We  have  since  met  with  it  in 
several  specimens  injected  by  Gerota's  method,  but  it  must  be  realized 
that  the  injection  of  these  vessels  is  somewhat  difficult,  and  that  success 
cannot  be  ensured  except  in  the  case  of  very  young  children. 

(2)  Marginal  Trunks. — Under  the  name  of  marginal  trunks, 
we  will  describe  all  the  collectors  which,  arising  from  the  network 
on  the  dorsal  surface  of  the  body  of  the  tongue,  cross  the  lateral 
borders  of  this  organ,  from  its  tip  to  the  V-shaped  groove  on  the 
dorsum.  They  vary  in  number  from  8  to  12. 

These  marginal  collectors  at  first  descend  almost  vertically 
beneath  the  mucous  membrane,  then  divide  into  two  groups  :  an 
external  which  descends  external  to  the  sublingual  gland,  and  an 
internal  which  runs  internal  to  this  gland. 

(a)  The  external  collectors,  3  or  4  in  number,  perforate  the  mylo- 
hyoid,  turn  round  the  inferior  border  of  the  mandible  and  terminate 
in  the  most  anterior  of  the  submaxillary  glands. 

(6)  The  internal  collectors,  usually  more  numerous  (5  or  6),  run 
obliquely  downwards  and  backwards,  remaining  in  contact  with 
the  muscular  body  of  the  tongue.  Though  the  course  of  these 
trunks  is  subject  to  some  variation,  their  usual  arrangement  may 
be  thus  classified.  Some  (d,  Fig.  105)  run  on  the  external  surface 
of  the  hyoglossus  and  are  placed  more  or  less  parallel  to  the  hypo- 
glossal  nerve.  Others  (c,  Fig.  105),  on  the  contrary,  pass  under  this 
muscle  and  then  become  satellites  of  the  lingual  artery  and  its 
branches.  All  end  in  the  glands  of  the  internal  jugular  chain. 
Generally  speaking,  the  more  anterior  their  lingual  origin  the  lower 
is  the  gland  to  which  they  pass. 

The  majority  of  them  terminate  in  a  large  gland  placed  beneath 
the  posterior  belly  of  the  diagastric,  and  in  which,  as  we  shall  shortly 
see,  some  of  the  collecting  trunks  which  come  from  the  base  of  the 
tongue,  also  terminate. 

In  the  course  of  these  marginal  trunks,  small  glandular  nodules 
are  often  met  with,  pointed  out  for  the  first  time  by  Kiittiier  and 
belonging  to  the  special  category  of  glands  which  we  have  termed 
para-visceral  (vide  General  Considerations,  p.  86).  As  may  be 
seen  in  Fig.  104,  these  glandular  nodules  may  be  situated  either 
under  the  sub-lingual  or  under  the  submaxillary  gland,  in  the 


276  SPECIAL    STUDY    OF    THE    LYMPHATICS 

anterior  or  posterior  part  of  the  digastric  triangle.  They  may  be 
termed  lateral  lingual  glands. 

(3)  Basal  Trunks.— We  have  seen  (p.  272)  that  the  rich  net- 
work which  surrounds  the  caliciform  papillae  gives  origin  to  7 
or  8  large  collectors.  These  are  the  posterior  or  basal  trunks. 
They  are  always  very  large,  and  represent  the  principal  lymphatic 
channel  of  the  tongue.  All  these  trunks  at  first  creep  underneath 
the  mucous  membrane  of  the  base  of  the  tongue,  but  at  this  point 
they  may  pursue  two  different  courses,  which  we  will  designate 
median  and  lateral. 

(a)  The  median  trunks  are  3  or  4  in  number.  They  are  always 
sinuous,  and  run  at  first  directly  from  before  backwards  in  the 
middle  line  as  far  as  the  lingual  insertion  of  the  median  glosso- 
epiglottidean  fold  ;  here  they  divide  into  two  groups  of  equal 
importance  which  run,  one  to  the  right,  the  other  to  the  left,  to  join 
the  lateral  trunks.  These  median  trunks  often  cross  each  other, 
and,  further,  it  is  not  unusual  to  see  one  of  them  bifurcate  at  the 
glosso-epiglottidean  fold  and  give  rise  to  two  secondary  trunks 
which  diverge  at  right  angles.  This  posterior  median  pedicle  is 
therefore  really  an  uneven  pedicle  at  the  level  of  which  the 
lymph  from  the  two  halves  of  the  tongue  mixes.  The  importance 
of  this  fact  from  a  pathological  point  of  view  can  be  understood. 

(6)  The  lateral  trunks,  two  in  number  on  either  side,  are  smaller 
than  the  preceding.  Springing  from  the  lateral  extremities  of  the 
network  which  surrounds  the  caliciform  papillae,  they  run  from 
before  backwards,  and  unite  with  the  preceding  at  the  lower  end 
of  the  tonsil.  As  they  pass  onwards,  the  posterior  trunks  receive 
some  very  delicate  lymphatics  coming  from  the  mucous  membrane 
of  the  base  of  the  tongue.  They  all  disappear  by  passing  deeply 
in  the  sub-amygdaloid  region,  but  traverse  the  pharyngeal  Avail  at 
different  points  ;  a  fact  which  we  can  readily  prove  in  an  injected 
specimen  by  looking  for  them  on  their  emergence  from  the  lateral 
wall  of  the  pharynx. 

It  may  then  be  observed  that  some,  after  traversing  the  superior 
constrictor  near  its  lingual  insertion,  appear  beneath  the  stylo- 
glossus,  and  at  first  embrace  the  dorsalis  linguae  and  then  the  lingual 
artery  itself  (/,  Fig.  105).  Other  trunks,  more  posterior,  emerge 
behind  the  preceding  through  the  superior  border  of  the  middle 
constrictor  (g,  Fig.  105).  All  terminate  in  a  large  gland  placed  on 
the  internal  jugular  immediately  beneath  the  posterior  belly  of  the 
digastric.  It  is  also  in  this  gland  that  some  of  the  marginal  trunks 


LYMPHATICS  OF  THE  HEAD  AND  NECK 


277 


terminate  as  we  have  already  seen  (d,  Fig.  105).    It  is  therefore  one 
of  the  most  important  of  the  glandular  termini  of  the  lymphatics 


FIG.  100. — Lymphatics  of  the  tongue,  anterior  view  (Poirier). 

The  inferior  maxilla  has  been  sawn  through  in  the  middle  line,  and  the  two  halves  drawn 
aside.  The  two  central  trunks  may  be  seen  running  between  the  two  genio-hyoglossi  which 
have  been  removed.  a.  Apical  trunk.  6.  Inconstant  trunk  ending  in  a  submaxillary 
gland,  c,  c.  Central  trunks.  d.  Intra-Ungual  glandular  nodule.  e.  Submaxillary 
gland.  /.  Principal  gland,  rj.  Centi'al  trunk  forming  a  loop  in  the  supra-hyoid  region 
before  ending  in  the  supra-omo-hyoid  gland,  h.  Supra -omo-hyoid  gland. 


278 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


of  the  tongue  :  Kiittner  calls  it  by  the  expressive  name  of  Hanpt- 
ganiglion  (h,  Fig.  105).  Some  basal  trunks  emerge  still  lower  down  ; 
they  perforate  the  thyro-hyoid  membrane  and  appear  beneath  the 
hyoid  bone  and  terminate  in  a  gland  which  lies  underneath  the  pre- 
ceding. Kiittner  has  seen  one  of  these  trunks  end  in  a  gland 
situated  much  deeper,  a  little  above  the  omo-hyoid  (i,  Fig.  105). 

(4)  Central  Trunks  (vide  Fig.  106). — The  central  trunks  arise 
from  the  middle  part  of  the  dorsal  network  of  the  body  of  the  tongue  ; 
instead  of  running  towards  the  lateral  parts,  they  descend  in  the 
middle  line  between  the  two  genio-hyoglossi  (c,  Fig.  106).  They  thus 

form  an  unequal  single  and 
median  pedicle  which  breaks  up 
into  two  secondary  pedicles  at 
the  inferior  border  of  these 
muscles  ;  at  this  point,  in  fact, 
they  pass  some  to  the  right, 
others  to  the  left.  They  are 
placed  between  the  genio-hyo- 
glossus  and  the  genio  -  hyoid 
muscles,  follow  the  deep  surface 
of  the  mylo-hyoid,  and  then 
appear  in  the  submaxillary  space. 
They  afterwards  pass  either  in 
front  of,  or  behind  the  pulley  of 
the  digastric,  and  crossing  the 
hyoid  bone  terminate  in  the 
glands  of  the  internal  jugular 
chain.  Some  of  them  end  in 
the  chief  gland  ;  others  in  a 
gland  lying  above  the  omo-hyoid 
(k,  Fig.  105,  and  gt  Fig.  106), 
others  finally,  in  glands  lying 
between  the  two  preceding. 

We  frequently  see  in  the  course 
of  these  vessels  small  glandular 
nodules,  placed  either  between 
the  two  genio-hyoglossi,  or  be- 
tween them  and  the  genio-hyoids. 

They  may  be  called  intra-lingual  glands  (d,  Fig.  106).  They  must 
not  be  confused  with  the  fusiform  dilatations  which  these  central 
trunks  occasionally  present. 


FIG.  107. — Lymphatics   of    the    tongue 

inferior  surface  (Poirier). 
The  tongue  has  been  detached  from  the 
maxilla  ;  the  two  genio-hyoglossi  being 
separated  from  each  other,  enable  the 
central  trunks  to  be  seen,  on  which  there 
are  fusiform  dilatations,  or.  Marginal  net- 
work. 6.  Central  trunk.  c.  Marginal 
trunk. 


LYMPHATICS    OF    THE    HEAD    AND    NECK  279 

To    sum    up,    the  lymphatics  of    the  tongue  terminate  in  the 
supra-hyoid  median,  the  submaxillary,  and  in  the  glands  of  the 
internal  jugular  chain,  but  the  relative  importance  of  these  different 
glandular  groups  considered  as  termini  of  the  lymphatics  of  the 
tongue  is  by  no  means  the  same.     The  supra-hyoid  median  glands 
only  receive  lymphatics  from  the  extreme  tip  of  the  tongue.     As 
regards  the  submaxillary  glands,  only  the  most  anterior  of  them  have 
lingual  lymphatics  as  direct  affluents,  and  the  three  or  four  trunks 
which  do  end  in  this  gland  drain  a  region  which  is  limited  to  the 
lateral  borders,  and  to  the  marginal  part  of  the  dorsum.     On  the 
other  hand,  all  the  glands  of  the  internal  jugular  chain,  included 
between  the  posterior  belly  of  the  digastric  and  the  spot  where  the 
vessels   are   crossed    by  the  omo-hyoid,  may   receive   lymphatics 
coming  from  the  tongue.     But,  here  again,  the  exact  number  of 
affluents  each  receives  has  to  be  determined  :    and  we  have  seen 
that  the  highest  of  these  glands,  i.e.  the  gland  placed  over  the 
internal  jugular,  immediately  beneatli  the  posterior  belly   of  the 
digastric,  should  be  regarded  as  the  principal  meeting-place  of  the 
lingual  lymphatics. 

Yoy.  sur  les  lymphatiques  de  la  langue  :  Kuttner.  Ueber  die  Lymphg.  n. 
Lytnphdr.  der  Zunge  mit  Beziehung  auf  die  Verbreitung  des  Zungencarcinoms. 
Beitz.  z.  klin.  Chir.,  1893,  xxi,  3,  p.  732. — Poirier.  Le  systeme  lymphatique  et 
le  cancsr  de  la  langue.  Gaz.  hebdom.,  11  Mai,  1902. 

LYMPHATICS  OF  THE  VAULT  OF  THE  PALATE. — The  lymphatics  of 
the  roof  of  the  palate  take  origin  from  a  network  with  very  fine 
meshes,  placed  in  the  most  superficial  portion  of  the  dermal  mucous 
membrane.  From  this  network  start  several  branches  which  run 
in  a  deeper  plane.  All  these  branches  run  obliquely  backwards 
and  inwards  towards  the  middle  line.  In  the  region  of  the  latter, 
they  unite  into  several  small  trunks  which  run  directly  backwards 
as  far  as  the  last  molars.  At  this  spot,  they  are  directed  outwards, 
pass  in  front  of  the  anterior  pillars  of  the  fauces,  and  then  perforate 
the  superior  constrictor  of  the  pharynx.  They  terminate  in  the 
glands  of  the  sub-sterno-mastoid  chain,  which  are  placed  on  the 
internal  jugular  vein,  immediately  beneath  the  point  where  this 
vessel  is  crossed  by  the  posterior  belly  of  the  digastric. 

The  lymphatic  network  of  the  roof  of  the  palate  is  continuous 
in  front  and  at  the  sides  with  that  of  the  gums,  and  behind  with 
that  of  the  inferior  surface  of  the  soft  palate. 

LYMPHATICS  OF  THE  SOFT  PALATE. — The  mucous  membrane  of 
the  soft  palate  is  extremely  rich  in  lymphatic  vessels.  The  two 


280  SPECIAL    STUDY    OF    THE    LYMPHATICS 

surfaces  of  the  palate,  its  free  border,  and  the  pillars  of  the  fauces 
are  covered  by  an  extremely  fine  network  which  is  continuous, 
without  a  clear  line  of  demarcation,  with  the  homologous  networks 
of  neighbouring  parts.  It  is  in  the  uvula  that  this  lymphatic 
network  is  richest.  Here,  "  the  lymph  channels  multiply  in  such 
abundance  that,-  after  successful  injections,  the  uvula  is  trans- 
formed into  a  little  knot  of  lymphatic  vessels.  It  then  increases 
to  twice  or  three  times  its  size,  and  one  might  think,  from 
this  turgidity,  that  we  were  witnessing  a  sudden  erection  " 
(Sappey). 

The  lymphatic  collectors  of  the  soft  palate  may  be  divided  into 
three  groups,  according  to  their  origin  from  the  superior  or  inferior 
surfaces,  or  from  the  pillars  of  the  fauces. 

1.  The  collecting  trunks  of  the  upper  surface  of  the  soft  palate 
run  backwards  and  outwards  below  the  pharyngeal  orifice  of  the 
Eustachian  tube  :  here,  they  unite  with  the  collectors  of  the  mucous 
membrane  of  the  nasal  fossae,  and  like  the  latter,  divide  into  two 
groups  :   (a)  some,  the  ascending  trunks,  run  backwards  and  upwards 
under    the    mucous    membrane   which   lines    the    lateral   walls    of 
the   pharynx.     Arrived  at   the    junction  of    the    lateral  and  pos- 
terior walls,  they  perforate  the  superior  constrictor  and  pass  into 
the  retro-pharyngeal  glands  ;    (b)  others,  the  descending  trunks,  run 
downwards  and  outwards,  passing  under  the  mucous  membrane 
of  the  posterior  pillars.     A  little  above   the  great  cornua  of  the 
hyoid  bone,  they  traverse  the  constrictors  and  terminate  in  the 
glands  placed  on  the  internal  jugular,  beneath  the  posterior  belly 
of  the  digastric. 

2.  The  collecting  trunks  of  the  inferior  surface  appear  on  the 
lateral  parts  of  this  surface.     They  run  downwards  and  forwards, 
under  the  mucous  membrane  of  the  anterior  pillars.     They  unite 
with  the  collectors  of  the  vault  of  the  palate,  then  like  the  latter, 
turn  round  the  anterior  pillar,  perforate  the  superior  constrictors, 
and  terminate  in  the  glands  of  the  internal  jugular  chain  which  are 
subjacent  to  the  posterior  belly  of  the  digastric. 

3.  The  collectors  of  the  anterior  -pillar  unite  with  the  preceding, 
pursuing  the  same  course  and  terminating  in  the  same  way.     The 
collectors  of  the  posterior  pillar  follow  the   same    course    as    the 
descending  collectors  of  the  superior  surface  of  the  palate  and  ter- 
minate in  the  same  glands  as  these  vessels.     However,  some  of 
•cftese  vessels  which  spring  from  the  lower  part  of  the  pillar  perforate 
the  wall  of  the  pharynx,  below  the  hyoid  bone,  and  terminate  in 


LYMPHATICS  OF  THE  HEAD  AND  NECK 


281 


the  glands  placed  over  the  internal  jugular,  at  the  level  of  the 
bifurcation  of  the  common  carotid. 

LYMPHATICS  OF  THE  PHARYNX. — The  lymphatic  apparatus  of 
the  pharynx  is  considerably  developed  as  regards  the  richness  of 
the  pharyngeal  mucous  membrane  in  lymphoid  tissue  (vide l  vol.  iv. 
p.  162  et  seq.). 

NETWORKS  OF  ORIGIN. — The  lymphatics  of  the  pharynx  arise 
from  two  networks,  one  mucous  and  the  other  muscular. 

The  mucous  network  spreads  beneath  the  pharyngeal  epithelium 
in  the  superficial  layer  of  the  mucous  cutis.  This  network  presents 


FIG.  108. — Lymphatics  of  pharynx. 

a,  b.  Retro-pharyngoal  glands,  c.  Interrupting  glandular  nodule,  placed  in  tho  course 
of  the  afferent  vessels  of  these  glands,  d.  Gland  of  the  deep  cervical  chain,  e.  Efferent 
vessel  of  retro-pharyngeal  glands,  passing  in  front  of  the  internal  carotid  artery.  /.  Afferent 
of  the  retro-pharyngeal  glands,  passing  behind  the  right  rectus  capitis  anticus  major. 
g-  Lymphatic  of  the  pharynx,  passing  directly  to  a  gland  of  the  deep  cervical  chain,  h. 
Afferent  of  retro-pharynueal  glands. 

its  maximum  of  development  in  the  mucous  membrane  which 
lines  the  posterior  surface  of  the  larynx,  and  the  pharyngeo-laryngeal 
pouches.  In  the  pharyngeal  tonsil  it  is  extremely  rich,  and  its 
meshes  become  remarkably  fine  (On  the  histological  origins  of  the 
lymphatics  of  the  tonsil,  vide1  vol.  iv.  pp.  90,  92).  The  network 
is  singularly  scanty  at  the  junction  of  the  pharynx  and  oesophagus, 
and  here  a  careful  examination  shows  that  the  small  branches  to 
which  it  gives  rise  tend  to  group  themselves  into  two  streams,  one 
ascending  or  pharyngeal,  the  other  descending  or  oesophageal 
(Most). 

1  Treatise  of  Human  Anatomy.     Poirier  and  Chttrpy. 


282  SPECIAL    STUDY    OF    THE    LYMPHATICS 

The  muscular  network,  which  is  of  much  less  importance,  has 
only  been  injected  by  Sappey  in  the  ox  and  horse. 

COLLECTING  TRUNKS. — From  these  two  networks,  but  more  par- 
ticularly from  the  mucous  network,  run  several  collectors  which  may 
be  divided  into  three  groups  :  superior,  middle  and  inferior. 

1.  The  superior  collecting  trunks  arise  from  the  vault  of  the 
pharynx,  from  the  lateral  wa^lls  of  the  nasal  pharynx,  and  from  the 
upper  half  of  the  posterior  wall. 

The  majority  of  these  vessels  are  directed  towards  the  posterior 
middle  line,  where  they  traverse  the  pharyngeal  wall.  They  then 
run  outwards,  enclosed  within  the  peri-pharyngeal  fascia,  and  ter- 
minate in  the  retro-pharyngeal  glands,  situated,  as  we  have  seen, 
at  the  junction  of  the  posterior  lateral  surfaces  of  the  pharynx, 
internal  to  its  sagittal  fascia.  In  their  course,  these  vessels  may 
present  small  interrupting  glandular  nodules,  which  are  in  more  or 
less  close  proximity  to  the  middle  line,  and  which  must  not  be  con- 
fused with  the  true  regional  glands,  which  are  always  lateral. 

Some  of  the  collecting  trunks  may  have  a  different  arrangement 
to  that  we  have  just  indicated  :  thus,  some  may  avoid  the  retro- 
pharyngeal  relay,  and  pass  directly  to  the  superior  and  middle 
glands  of  the  internal  jugular  chain,  running  obliquely  behind  the 
sympathetic  and  the  large  vessels  and  nerves.  Some  of  these 
vessels  pass  behind  the  rectus  capitis  anticus  major,  between  the 
latter  and  the  vertebral  column  (vide  Fig.  108). 

Finally,  some  of  the  collecting  trunks,  instead  of  emerging  from 
the  posterior  middle  line,  perforate  the  pharyngeal  Avail  at  the 
junction  of  its  posterior  and  lateral  surfaces,  and  terminate  at  once 
in  the  retro-pharyngeal  glands  ;  but  this  shortened  course  is  the 
exception,  and  Most  is  right  in  insisting  that  the  collecting  trunks 
usually  emerge  from  the  middle  line  in  the  upper  part  of  the 
pharynx  (vide  Fig.  108). 

2.  The  middle  collectors  arise  from  the  amygdaloid  region  and 
from  the  mucous  membrane  of  the  adjacent  parts.     These  vessels 
perforate  the  muscular  coat  a  little  above  the  great  cornu  of  the 
hyoid  bone,  and  terminate  in  the  glands  placed  on  the  internal 
jugular,  immediately  beneath  the  posterior  belly  of   the  digastric. 

3.  The  inferior  collectors  arise  from  the  whole  of  the  inferior 
portion  of  the  pharynx.     They  converge  towards  the  middle  portion 
of  the  pharyngeo-lateral  pouches  (sinus  pyriformis),  running  under- 
neath the  mucous  membrane.     Here,  they  unite  with  the  lymphatics 
which  constitute  the  superior  pedicle  of  the  larynx,  and  have  a 


LYMPHATICS  OF  THE  HEAD  AND  NECK    283 

similar  termination.  They  thus  end  in  4  or  5  glands  of  the  internal 
jugular  chain  which  lie  along  this  vessel,  or  immediately  behind  it, 
between  the  posterior  belly  of  the  digastric  and  the  middle  part  of 
the  thyroid  body.  These  collecting  trunks  usually  present  in  their 
course  small  interrupting  glandular  nodules  placed  on  the  external 
surface  of  the  thyro-hyoid  membrane  (vide  Fig.  110). 

To  sum  up,  the  lymphatics  of  the  pharynx  end  either  in  the  retro- 
pharyngeal  glands  or  in  the  glands  of  the  internal  jugular  chain. 
The  glands  of  this  chain  which  receive  the  lymphatics  of  the 
pharynx  all  belong  to  the  internal  group  of  the  sub-sterno-mastoid 
glands  (vide  p.  257). 

Surles  lymphatiques  du  pharynx,  voy.  :  Most.  Ueber  den  Lymphgefas- 
sapparat  von  Nase  und  Rachen.  Arch.  /.  Anat.  und  Phys.,  Anat.  Abth., 
1901,  p.  74. 

LYMPHATICS  OF  THE  CERVICAL  PORTION  OF  THE  OESOPHAGUS. — 
The  lymphatics  of  the  cervical  portion  of  the  oesophagus  take  origin 
from  two  networks,  one  mucous  and  the  other  muscular.  As  we 
have  seen,  the  mucous  network  at  its  upper  part  is  relatively 
independent  of  the  homologous  network  of  the  pharynx.  The 
collecting  trunks  coming  from  these  two  networks  terminate  in  the 
sub-sterno-mastoid  glands  and  in  the  glands  of  the  recurrent  chain. 

4.     LYMPHATICS  OF  THE  FACIO-CERVICAL  PORTION  OF  THE 
RESPIRATORY  PASSAGES. 

LYMPHATICS  OF  THE  NASAL  FOSSAE. — NETWORK  OF  ORIGIN. — The 
lymphatics  of  the  nasal  fossae  arise  from  a  continuous  network, 
placed  in  the  most  superficial  part  of  the  cerium  of  the  mucous 
membrane.  The  appearance  of  this  network  varies  considerably 
in  different  regions.  At  the  posterior  extremity,  or  tail  of  the 
superior  turbinate  bone,  this  lymphatic  network  presents  its 
maximum  development.  It  is  here  that  the  first  attempt  at 
injection  must  be  made.  It  also  presents  somewhat  closely  set 
meshes  on  the  inferior  wall  of  the  nasal  fossae  and  over  the  turbinate 
bones  and  the  middle  and  inferior  meatuses.  On  the  other  hand, 
the  small  branches  which  compose  it,  become  extremely  fine  on 
the  superior  turbinate  bone  and  over  the  whole  of  the  internal  wall, 
and  in  these  places,  their  injection  presents  great  difficulties.  This 
is  also  the  case  the  nearer  we  approach  the  anterior  orifice  of  the 
nasal  fossae.  As  a  general  rule,  the  richness  of  the  network  and 
the  ease  with  which  it  can  be  injected  are  here,  as  everywhere,  in 
direct  proportion  to  the  thickness  of  the  mucous  membrane. 


284  SPECIAL    STUDY    OF    THE    LYMPHATICS 

This  network  of  origin  is  continuous  in  front  with  the  cutaneous 
network  of  the  vestibule  of  the  nasal  fossae.  Behind,  it  is  con- 
tinuous with  that  of  the  pharynx  and  the  upper  surface  of  the 
soft  palate.  At  the  back  part  of  the  septum,  there  is  a  continuity 
between  the  networks  of  the  two  nasal  fossae  ;  thus,  a  unilateral 
puncture  of  the  septum  may  inject  the  collectors  of  the  nasal  fossae 
of  the  opposite  side. 

In  the  olfactory  region  of  the  mucous  membrane  of  the  nasal  fossae,  there- 
are  present,  by  the  side  of  the  lymphatic  networks  properly  so  called, 
formations  which  are  to  a  certain  extent  comparable  with  them  ;  these  are 
the  meningeal  sheaths  of  the  filaments  of  the  first  pair  of  nerves.  Now. 
when  these  sheaths  are  injected  through  the  sub-arachnoidean  space,  it  some- 
times happens  that  the  lymphatics  of  the  nasal  mucous  membrane 
are  filled  at  the  same  time  (vide1  vol.  iii.  p.  777,  Fig.  421).  Axel,  Key 
and  Retzius,  who  first  pointed  out  this  fact,  have  however  never 
seen  direct  communications  between  the  periolfactory  sheaths  and  the  lym- 
phatics of  the  mucous  membrane.  The  injection  passed  into  the  latter  by 
means  of  fine  canals  which  traversed  the  foramina  of  the  cribriform  plate 
at  the  same  time  as  the  olfactory  filaments,  though  remaining  independent 
of  the  lymphatic  sheaths  of  the  latter.  According  to  Key  and  Retzius, 
there  is  therefore  direct  communication  between  the  sub-arachnoidean  space 
and  the  lymphatics  of  the  pituitary  body.  We  confess  we  are  not  absolutely 
convinced  of  the  reality  of  this  communication.  On  account  of  the  practi- 
cal interest  which  is  attached  to  this  question,  from  the  standpoint  of  the 
pathogeny  of  certain  cerebral  lesions  consecutive  to  nasal  infections,  we  think 
it  advisable  that  further  researches  should  be  undertaken  on  this  particular 
point  regarding  the  anatomy  of  the  lymphatics  of  the  pituitary  body. 

THE  COLLECTING  TRUNKS  of  the  network  of  the  nasal  fossae 
form  two  groups  :  anterior  and  posterior. 

(a)  The  anterior  trunks,  which  are  of  much  less  importance,  can 
only  be  injected  by  punctures  made  into  the  anterior  third  of  the 
mucous  membrane  of  the  nasal  fossae.  Varying  in  number,  they 
run  either  in  the  groove  which  separates  the  triangular  cartilage 
of  the  nose  from  the  bony  orifice  upon  which  it  rests,  or  between  the 
different  cartilages,  or  even  in  front  of  them.  They  thus  arrive 
at  the  cellule-adipose  subcutaneous  tissue,  where  they  unite  into 
two  trunks  which  more  or  less  closely  embrace  the  facial  vein  and 
terminate  in  the  submaxillary  glands  (Most).  They  anastomose 
with  the  lymphatics  of  the  integuments  of  the  nose  (vide  p.  265). 

(6)  The  posterior  trunks,  which  are  much  larger  than  the  pre- 
ceding, constitute  the  principal  lymphatic  channel  of  the  nasal  fossae. 
They*  arise  at  the  junction  of  the  nasal  fossae  and  the  pharynx, 
below  and  a  little  in  front  of  the  pharnygeal  orifice  of  the  Eustachian 
tube.  Here  there  is  a  kind  of  centre  around  which  the  meshes 
of  the  adjacent  portions  of  the  network  appear  to  group  themselves, 
1  Treatise  of  Human  Anatomy,  Poirier  and  Charpy. 


LYMPHATICS  OF  THE  HEAD  AND  NECK 


285 


and  which  constitutes  the  general  meeting-place  of  the  lymphatics 
of  the  pituitary.  The  trunks  originating  from  this  region  may 
follow  two  courses  :  a  primary  group  of  collecting  trunks  (2  or  3) 
runs  downwards  and  outwards,  under  the  mucous  membrane  of 
the  posterior  pillar.  Slightly  above  the  great  cornu  of  the  hyoid 
bone,  these  vessels  unite  with  the  lymphatics  coming  from  the 
tonsillar  region,  perforate  the  muscular  coat  of  the  pharynx  and 
terminate  in  1  or  2  glands  lying  on  the  internal  jugular  below  the 
posterior 

\\.\      ^     ;/:.:.:  iv»  IN&^.XL^V:;.;.  _ 


belly  of  the 
digastric. 
As  we  have 
already  seen 
(p.  257), 
these  glands 
belong  to 
the  internal 
group  of  the 
sub  -  sterno- 
m  a  s  t  o  i  d 


Nasal  lymphatics 

Retro-pharyngeal  gland 
J '(trot  id  gland 
1'arotid  gland 
rot  id  gland 

Sub-parotid  gland 


FIG.    109. — .Scheme  of  the  course  of  the  collecting  trunks  of   the 
nasal  fossae  ending  in  the  retro-pharyngeal  glands. 


glands.  The  second  group  of  these  collectors  comprises  2  to  4 
vessels  which  are  larger  than  the  preceding.  These  run  from 
before  backwards  on  the  lateral  wall  of  the  pharynx,  coursing 
underneath  the  mucous  membrane.  When  they  arrive  at  the 
junction  of  the  lateral  and  posterior  walls  of  the  pharynx,  they 
perforate  the  superior  constrictor,  and  terminate  in  the  retro- 
pharyngeal  glands  (vide  p.  257). 

To  sum  up,  the  lymphatics  of  the  mucous  membrane  of  the  nasal 
fossae  terminate  in  the  retro-pharyngeal  glands,  in  the  upper  glands 
of  the  internal  jugular  chain,  and  very  occasionally  in  the  sub- 
maxillary  glands.  The  retro-pharyngeal  group  is  of  particular 
importance,  for,  at  whatever  point  the  mucous  membrane  happens 
to  be  punctured,  these  glands  are  always  coloured  by  the  injected 
material  (Most). 

Lymphatics  of  the  Sinuses.— Our  knowledge  of  the  lymphatics 
of  the  mucous  membrane  which  lines  the  cells  and  sinuses  of  the 
nasal  fossae  is  still  imperfect.  The  small  degree  of  development 
which  these  cavities  present  in  the  infant  (the  usual  subject  for 
experimentally  injecting  the  lymphatics)  renders  the  study  of 
these  lymphatics  somewhat  difficult.  A  priori,  if  we  base  our 
opinions  on  the  origin  of  these  cavities  and  the  arrangement  of 


286 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


their  blood  vessels,  as  described  by  Zuckerkaiid,  we  may  admit  that 
their  lymphatics  end  in  the  same  glands  as  those  of  the  nasal  fossae. 
Moreover,  this  is  what  the  researches  of  Most  appear  to  demon- 
strate, in  whose  opinion,  all  the  cells  and  sinuses,  including  the 
frontal  sinuses,  send  their  lymphatics  into  the  retro-pharyngeal 
glands.  The  existence  of  lymphatics,  traversing  the  outer  wall 
of  these  cavities  to  join  the  lymphatics  of  the  face,  is,  however, 
possible  ;  but  up  to  the  present  no  one  has  succeeded  in  injecting 
them. 

The  lymphatics  of  the  nasal  fossae  were  well  described  for  the  first  time  by 
E.  Simon  (1859).  Sappey  injected  them  in  man,  the  horse,  the  sheep  and 
the  ox,  and  gave  an  excellent  description  of  their  network  of  origin.  Quite 
recently,  Most  has  studied  the  collecting  trunks  of  this  network  and  has 
described  them  very  completely. — Most.  Ueber  den  Lymphgefassapparat  von 
Nase  und  Rachen.  Arch.  f.Anat.  u.  Entivickelungsyesch.,  Anat.  Abth.,  1901,  p. 74. 

LYMPHATICS  OF  THE  MIDDLE  EAR. — Our  knowledge  of  the  lym- 
phatics of  the  tympanum  is  still 
very  imperfect.  It  is  admitted 
that  these  vessels  spring  from  a 
network  attached  to  the  mucous 
membrane,  and  terminate  in  the 
glands  contained  in  the  parotid 
space  and  in  the  retro-pharyngeal 
glands.  The  lymphatics  of  the 
Eustachian  tube  run  towards  its 
pharyngeal  orifice  and  terminate 
in  the  retro-pharyngeal  glands. 
On  account  of  the  importance  of 
these  vessels  from  a  practical  point 
of  view,  we  think  their  study  should 
be  undertaken  again. 

LYMPHATICS  or  THE  LARYNX.— 
NETWORK  OF  ORIGIN. — The  network 
of  origin  of  the  lymphatics  of  the 
larynx  extends  over  the  whole  of 
the  internal  surface  of  the  organ. 
It  is  densest  where  the  mucous 
membrane  is  thickest.  We  may 
regard  it  as  formed  of  two  distinct 
regions,  corresponding  respectively 
to  the  supra  and  infra-glottic  zone 
of  the  larynx. 


FICJ.  110. — Lymphatics  of  the  larynx 

(after  Most). 

a,  b.  Thyro-hyoid  glandular  nodules 
placed  in  the  course  of  the  collecting 
trunks  coming  from  the  pharvngeo- 
laryngeal  sinuses,  c,  c.  Glands  of  the 
internal  jugular  chain,  rf.  Collecting 
trunk  of  the  superior  pedicle,  e,  /. 
Collecting  trunk  of  the  middle  pedicle. 
(j.  Gland  of  the  recurrent  chain,  h, 
Prae-tracheal  gland. 


LYMPHATICS    OF    THE    HEAD   AND   NECK  287 

In  the  upper  region,  the  network,  which  is  extremely  dense  and 
very  easy  to  inject,  covers  the  epiglottis,  the  aryteno-epiglottic 
folds,  the  superior  vocal  cords,  and  the  ventricles  of  the  larynx. 
The  network  of  the  lower  region,  though  equally  well  developed, 
is  however  not  so  plentiful  as  the  supra-glottic  network. 

These  two  regions  are  separated  by  the  inferior  vocal  cords,  in 
the  region  of  which  the  lymphatic  vessels  are  very  scanty  and 
very  thin.  The  drying  of  the  mucous  membrane,  which  is  here 
very  fine,  renders  the  injection  of  this  glottic  network  somewhat 
difficult  (Poirier).  When  this  network  is  injected,  the  injection 
usually  passes  into  the  vessels  of  the  supra-glottic  zone,  more 
rarely  into  those  of  the  sub-glottic  zone  (Most).  Though  the  two 
lymphatic  territories  of  the  larynx  largely  communicate  with 
each  other  in  the  posterior  wall  of  the  larynx,  ifc  is  rare  to  obtain 
a  complete  injection  of  the  endo-laryngeal  network  by  puncturing 
only  one  of  these  territories.  It  may  be  added  that  the  injections 
easily  cross  the  middle  line  ;  but  though  the  mass  injected  into 
one  half  of  the  larynx  easily  passes  into  the  mucous  membrane 
of  the  other  side,  it  is,  on  the  other  hand,  exceptional  for  it  to  pass 
as  far  as  the  corresponding  glands  of  that  side.  The  lymphatics 
of  the  larynx  anastomose  to  a  large  extent  with  the  networks  of 
the  adjacent  organs  (tongue,  pharynx,  trachea). 

II.  COLLECTING  TRUNKS.  —  1.  The  trunks  coming  from  the 
supra-glottic  network  are  directed  towards  the  lateral  borders  of 
the  epiglottis  and  the  aryteno-epiglottic  folds  ;  they  afterwards 
descend  into  the  sinus  pyriformis,  and  then  perforate  the  thyro- 
hyoid  membrane  at  the  spot  where  the  superior  laryngeal  artery 
enters.  Here,  they  usually  number  from  4  to  5.  After  emerging, 
they  diverge.  One  or  two  ascend,  cross  the  hypoglossai  nerve, 
and  end  in  a  sub-sterno-mastoid  gland  placed  immediately  below 
the  posterior  belly  of  the  digastric.  One  or  two  middle  trunks, 
horizontally  placed,  reach  the  glands  placed  on  the  internal  jugular 
vein  opposite  the  bifurcation  of  the  common  carotid.  Finally, 
one  or  two  descending  trunks  terminate  in  the  glands  belonging 
to  the  same  chain,  but  situated  lower  down,  at  the  level  of  the 
middle  part  of  the  lateral  lobes  of  the  thyroid  body  (vide  Fig.  110). 

2.  The  trunks  coming  from  the  subglottic  region  are  grouped  into 
two  distinct  pedicles,  one  anterior,  and  the  other  posterior. 

(a)  The  anterior  or  supra-cricoid  pedicle  is  formed  by  3  or  4 
trunks  which  come  through  the  crico-thyroid  membrane  near 
the  middle  line.  One  and  sometimes  two  of  these  trunks  end  in 


288 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


the  praelaryngeal  glands  (vide  p.  261),  while  a  third  passes  in 
front  of  the  isthmus  of  the  thyroid  body  and  empties  itseir  into  a 
prae-tracheal  gland  (Most)  ;  one  or  several  others  run  do \vmvarcb 

and  outwards,  towards 
one  of  the  middle  glands 
of  the  internal  jugular 
chain  (vide  Fig.  110). 

(b)  The  posterior  or  siib- 
cricoid  pedicle  traverses 
the  crico -trachea!  mem- 
brane at  the  junction  of 
the  lateral  and  posterior 
surfaces  of  the  trachea. 
It  includes  several  trunks 
which  embrace  the  re- 
current laryngeal  nerve 
and  the  terminal  part  of 
the  inferior  laryngeal  ar- 
tery, and  terminate  in 
the  glands  of  the  recur- 
rent chain.  From  the 
latter  glands  run  some 
trunks  which  pass  to  the 
sub-sterno  -  mastoid  and 
supra  -  clavicular  glands 
(vide Fig.  111).  The  trunks 
of  the  posterior  pedicle 
anastomose  with  the  lym- 
phatic vessels  of  the 

thyroid  body,  and,  when  they  are  injected,  we  often  obtain 
a  partial  injection  of  the  perithyroidean  network. 

To  sum  up,  the  lymphatics  of  the  larynx  end  in  the  glands  of 
the  recurrent  chain,  in  the  sub-sterno-mastoid  glands,  and  accessorily 
in  the  supra-clavicular  glands.  The  sub-sterno-mastoid  glands 
represent  their  principal  terminus.  In  this  connexion  we  should 
remark  that  the  laryngeal  lymphatics,  like  the  majority  of  the 
other  lymphatics  of  the  neck,  are  more  particularly  distributed 
to  the  inner  glands  of  this  group,  i.e.  to  the  glands  arranged  ver- 
tically along  the  internal  jugular  vein.  As  regards  the  prae- 
laryngeal glands,  we  have  seen  above  (p.  261)  that  they  have  to 
be  regarded  not  as  regional  glands,  but  as  simple  interrupting 


FIG.  111. — Recurrent  chain  (after  Roubaud). 

a,  a.  Praehiryngeal  glands.  b.  Praecricoid 
gland.  c.  Gland  of  the  recurrent  chain,  rf. 
Gland  of  the  external  jugular  chain.  /.  Superior 
thyroid  artery.  fj.  Internal  jugular  vein.  h. 
Innominate  artery,  i.  Left  common  carotid 
artery.  7.  Left  sub-clavian  artery. 


LYMPHATICS  OF  THE  HEAD  AND  NECK     289 

glandular  nodules  placed  over  the  course  of  the  collecting  trunks 
of  the  middle  group. 

It  is  interesting  to  remark  in  passing  that  the  small  glands  which  are  found 
on  the  thyro-hyoid  membrane,  near  the  spot  where  the  trunks  of  the  superior 
pedicle  emerge,  receive  no  lymphatics  coming  from  the  larynx.  They  are 
attached  to  the  collectors  which  spring  from  the  pharyngo-laryngeal  sinuses  ; 
they  therefore  belong  to  the  lymphatic  apparatus  of  the  pharynx  (vide 
pp.  282  and  283). 

BIBLIOGRAPHY — Poirier.  Lymphatiques  du  larynx.  Proyres  medical,  1887, 
No.  19. — Most.  Ueber  die  Lymphgefasse  u:  Lymphdriisen  des  Kehlkopfes. 
Anat.  Anz.,  1899,  pp.  387,  393. — Most.  Ueber  den  Lymphgefassapparat  von. 
Kehlkopf  u.  Trachea,  etc.,  Deutsche  Zeitschr.  /.  Chir.,  1900,  Ivii.  p.  199. — 
Koubaud.  Contribution  a  1' etude  des  lymphatiques  clu  larynx.  These  Paris,  1902. 

LYMPHATICS  OF  THE  CERVICAL  PORTION  OF  THE  TRACHEA. — 
These  lymphatics  arise  from  a  submucous  network,  which  is  very 
scanty  and  difficult  to  inject.  The  trunks  coming  from  it  run 
in  the  intercartilaginous  spaces,  perforate  the  latter  close  to  their 
posterior  extremities,  and  terminate  in  the  glands  of  the  recurrent 
chain. 

LYMPHATICS  OF  THE  THYROID  BODY.  — NETWORK  OF  ORIGIN.— 
The  lymphatic  vessels  of  the  thyroid  body,  the  origin  of  which  u'o 
need  not  here  recall  (vide  vol.iv.  pp.  578,  58 11), eventually  terminate 
in  a  network  placed  within  the  actual  thickness  of  the  capsule  of 
this  organ.  To  this  network  may  be  attached  some  small  glands 
to  which  Most  has  recently  drawn  attention.  Legendre,  too,  some 
time  ago  pointed  out  the  possible  presence  of  a  gland  at  the 
posterior  border  of  the  lateral  lobes  of  the  gland,  slightly  above 
their  lower  extremities  ;  but  these  old  observations  must  be  ap-ceptfcl 
with  reserve,  on  account  of  a  possible  confusion  with  the  parathyroid 
glands,  which  were  then  unknown. 

II.  COLLECTING  TRUNKS. — From  the  peri-thyroidean  capsular 
network  run  two  kinds  of  trunks,  one  ascending,  the  other  descend- 
ing. 

1.  The  ascending  trunks  are  partly  median  and  partly  lateral. 
The  median  trunks  detach  themselves  from  the  superior  border  of 
the  isthmus  and  reach  the  praelaryngeal  gland  (Legendre,  Gerard, 
Marchant).     The  lateral  more  or  less  exactly  follow  the  course  of 
the  superior  thyroid  artery,  and  end  in  the  sub-sterno-mastoid  glands, 
placed  at  the  bifurcation  of  the  common  carotid. 

2.  The  descending  trunks  also  form  two  groups,  some  of  which 
the  median,  reach  the  praetracheal  glands  ;    others,   the  lateral 
pass  to  the  glands  of  the  recurrent  chain. 

1  Treatise  of  Human  Anatomy.     Poirier  and  Charpy, 

S 


CHAPTER  VI 

TERMINAL   COLLECTING    TRUNKS    OF   THE 
LYMPHATIC  SYSTEM 

THE  terminal  collecting  trunks  of  the  lymphatic  system  all  finally 
end  in  the  junction  of  the  internal  jugular  and  sub-clavian  veins. 
It  is  quite  exceptional  to  see  lymphatic  vessels  terminate  at  other 
points  of  the  venous  system.  The  endings  formerly  described  by 
Lippi  (1830)  in  the  inferior  vena  cava,  portal  vein,  etc.,  and  more 
recently  by  Leaf  into  the  femoral  vein,  are  not  admitted  to-day  by 
any  other  anatomist. 

The  lymphatics  of  the  sub-diaphragmatic  portion  of  the  body 
unite  to  form  a  single  canal,  the  thoracic  duct,  which  terminates  in 
the  junction  of  the  internal  jugular  and  left  sub-clavian  veins. 
The  lymphatics  of  the  sub-diaphragmatic  portion  resolve  them- 
selves both  on  the  right  and  left  sides,  into  three  collecting  trunks, 
viz.  the  jugular,  the  sub-clavian,  and  the  broncho-mediastinal .  On 
the  left  side,  these  vessels  are  often  only  simple  affluents  of  the 
terminal  segment  of  the  thoracic  duct.  On  the  right,  they  some- 
times unite,  but  not  very  often,  into  a  common  trunk — the  right 
lymphatic  duct. 

§  1.  TERMINAL   COLLECTING   TRUNKS    OF   THE    SUPRA- 
DIAPHRAGMATIC    PORTION    OF    THE    BODY. 

As  we  have  just  seen,  the  lymphatics  of  each  of  the  two  halves  of 
the  supra-diaphragmatic  portion  of  the  body  are  finally  reduced 
to  three  collecting  trunks  :  the  jugular  trunk,  which  comprises 
the  lymphatic  circulation  of  the  corresponding  side  of  the  head  and 
neck,  and  is  formed  by  the  confluence  of  the  efferent  vessels  of  the 
inferior  glands  of  the  deep  cervical  chain  ;  the  sub-clavian  trunk, 
which  is  formed  by  the  union  of  the  majority  of  the  efferent  vessels 
of  the  axillary  glands,  and  drains  the  lymph  from  the  upper  limb 
of  the  corresponding  side  ;  the  broncho-mediastinal  trunk,  which,  on 
each  side,  results  from  the  union  of  the  efferents  of  the  internal 
mammary  chain  and  those  of  the  anterior  mediastinal  and  peri- 
tracheal-bronchial  glands,  and  thus  receives  the  majority  of 

290 


TERMINAL    COLLECTING    TRUNKS 


291 


parietal  lymphatics  and  the  whole  of  the  visceral  lymphatics  of  the 
thorax.  Each  of  these  trunks  is  often  double,  sometimes  even 
triple.  Their  mode  of  termination  in  the  venous  junction  varies 
on  the  two  sides. 

ON  THE  RIGHT,  we  may  meet  with  the  following  arrangements  :— 
The  three  terminal  collecting  trunks  may  open  separately  into 
the  venous  junction.  This  is  the  most  usual  arrangement.  The 
subclavian  and  internal  jugular  trunk  then  terminate  very 
close  to  one  another,  near  the  apex  of  the  angle  which  is  open  above 
and  externally,  and  formed  by  the  union  of  the  internal  jugular  and 
subclavian.  The  broncho-mediastinal  trunk  terminates  in  the 


Fics.  112.— Terminal  collecting  trunks  of  the  right  half  of  the  supra-diaphragmatic 

portion  of  the  body. 

a.  Jugular  trunk,  b.  Subclavian  trunk,  r.  Broncho-mediastinal  trunk,  d.  Right 
lymphatic  duct.  e.  Gland  of  the  internal  mammary  chain.  /.  Gland  of  the  deep  cervical 
chain. 

anterior  surface  of  the  venous  junction  (vide  a,  Fig.  112). 

In  other  cases,  the  sub-clavian  and  the  jugular  trunks  unite  into 
a  common  trunk  (vide  6,  Fig.  112).  This  trunk  is  usually  styled 
the  right  lymphatic  duct.  It  is  always  very  short  and  rarely  exceeds 
10  to  12  millimetres.  This  arrangement  is  moreover  rare,  seeing 
that  Grossmann  only  met  with  it  once  in  twenty-five  subjects  ;  and 
further,  it  should  be  mentioned  that  in  this  case,  the  subclavian 
trunk  was  double  and  that  the  more  important  of  the  two  secondary 
trunks  passed  directly  into  the  venous  confluence.  The  right 
lymphatic  duct  is  therefore  most  usually  absent.  It  is  still  more- 
rare  to  see  the  bronchio-mediastinal  trunk  unite  with  the  two  pre- 
ceding to  form  with  them  a  single  trunk  (vide  c,  Fig.  112).  It  is 
less  rare  to  see  it  unite  with  the  subclavian  trunk,  and  remain 
independent  of  the  jugular  trunk. 


292 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


We  may  add  that  the  possible  division  into  two  of  the  three 
trunks  and  the  different  terminations  which  each  of  their  bifurca- 
tion branches  may  then  show,  increase  so  to  speak,  almost  inde- 
finitely the  varieties  which  may  be  met  with. 

ON  THE  LEFT,  the  jugular  trunk  usually  empties  itself  into  the 
terminal  bend  of  the  thoracic  duct.  The  subclavian  trunk  and 
the  broncho-mediastinal  trunk  open  directly  into  the  venous  con- 
fluence, either  separately  or  else  by  forming  a  common  trunk. 
These  two  vessels  may  also  terminate  in  the  thoracic  duct,  but  it 
is  true  that  this  arrangement  is  somewhat  rare.  In  twenty-five 
subjects,  Grossmann  has  only  twice  seen  the  left  axillary  trunk 
empty  itself  into  the  thoracic  duct.  In  these  two  cases,  moreover, 
the  axillary  trunk  was  double,  and  one  of  its  terminal  branches 
passed  directly  into  the  venous  junction.  The  termination  of  the 
left  broncho-mediastinal  trunk  in  the  thoracic  duct  is  still  more  rare. 


BLAJSl.S- 

FIG.  113. — Thoracic  duct  (after  Mascagni). 
1.  Thoracic   duct.       2.     Right    lymphatic    duct.       3. 
Origin  of  thoracic  duct.     4.  Terminal   part  of  the  duct 
forming  an  arch   and   opening  into  the  junction  of  the 
internal  jugular  and  sub-clavian  veins. 


§    2.    THE    THORACIC 
DUCT. 

THE  thoracic  duct 
(Ductus  thoracicus, 
Milchbrustyang)  ex- 
tends from  the 
second  lumbar  verte- 
bra where  it  origin- 
ates, to  the  junction 
of  the  internal  jugu- 
lar and  left  sub- 
clavian veins,  where 
it  terminates.  It  is 
the  common  collector 
of  all  the  lymphatic 
vessels  of  the  sub- 
diaphragmatic  por- 
tion of  the  body,  and 
moreover, frequently, 
but  not  invariably 
receives  the  left 
jugular,  subclavian, 
and  internal  mam- 
mary trunks  which 


TERMINAL    COLLECTING    TRUNKS 


293 


bring  the  lymph  from   the    left   supra-diaphragmatic    portion    of 
the  body. 

COURSE,  DIRECTION. — The  thoracic  duct  usually  commences  at 
the  upper  border  of  the  second  lumbar  vertebra.  It  is  rare  for 
it  to  arise  below  this  point.  On  the  other  hand,  it  is  often  situated 
on  the  first  lumbar  or  even  on  the  twelfth  dorsal.  It  runs  at  first 
vertically  upwards,  passing  a  little  to  the  right  of  the  middle  line. 
Then  from  the  sixth  to  the  fourth  dorsal,  it  changes  its  direction 
and  runs  obliquely  upwards  and  to  the  left,  in  this  manner  crossing 
the  anterior  surface  of  the  vertebral  column  in  a  slanting  direction, 
and  continuing  its  ascending  course  as  far  as  a  horizontal  line 
drawn  through  the  lower  border  of  the  body  of  the  sixth  cervical 
vertebra.  At  this  point  it  quickly  changes  its  direction,  describes 
a  curve  with  the  concavity  downwards,  and  runs  downwards, 
outwards  and  forwards  and  terminates  in  the  venous  junction. 

If  the  thoracic  duct  is  considered  from  the  point  of  view  of  its 
direction,  we  may  re- 
gard it  as  being  divisible 
into  two  portions  :  an 
a s c ending  portion, 
measuring  from  27  to  30 
centimetres,  and  a  de- 
scending portion,  which 
is  only  3  to  4  centimetres 
in  length.  The  ascend- 
ing portion  is  itself 
formed  of  two  segments  : 
one  vertical  and  the 
other  oblique  ,  but  this 
division  into  two  seg- 
ments is  by  no  means 
always  clear,  and  in  a 
great  many  subjects,  the 
thoracic  duct  inclines  so 
gradually  to  the  left,  that 
it  is  impossible  to  state 
the  precise  spot  at  which 
the  change  of  direction 
commences. 

The    thoracic    duct  is 
slightly     sinuous.      The 


Fus.  114.— -.Abdominal  portion  of  the  thoracic  duct. 


294  SPECIAL    STUDY    OF    THE    LYMPHATICS 

more  advanced  in  age  the  subject  the  more  marked  have  the 
sinuosities  appeared  to  be.  In  the  new-born  the  duct  is  almost 
straight. 

CALIBRE. — The  calibre  of  the  thoracic  duct  varies  in  different 
parts.  At  its  origin,  it  has  a  dilated  portion  which  is  generally 
termed  reservoir  or  cistern  of  Pecquet  (cisterna  chyli,  receptaculum 
chyli).  This  enlarged  portion,  which  may  however  be  absent,  is 
most  frequently  pyriform  in  shape  ;  it  usually  terminates  at  the 
level  of  the  body  of  the  eleventh  dorsal  vertebra.  It  is  in  the 
middle  part  of  its  course  that  the  thoracic  duct  is  least  developed. 
It  here  only  measures  from  4  to  6  millimetres  in  diameter.  This 
calibre  is  much  greater  again  near  its  termination.  Here  there 
is  sometimes  a  slight  dilatation,  represented  by  Mascagni  and 
called  the  ampulla  of  the  thoracic  duct. 

RELATIONS. — From  the  point  of  view  of  its  relations,  the  thoracic 
duct  may  be  regarded  as  formed  of  three  parts  :  viz.  an  abdominal, 
a  thoracic  and  a  cervical  part. 

ABDOMINAL  PART. — The  abdominal  part  extends  from  the  superior 
border  of  the  second  lumbar  vertebra  to  a  horizontal  line  passing 
through  the  upper  part  of  the  aortic  orifice  of  the  diaphragm,  and 
corresponding  to  the  lower  border  of  the  twelfth  dorsal  vertebra. 
In  this  portion  the  thoracic  duct,  or  more  correctly  speaking  the 
receptaculum  chyli,  is  in  relation  in  front,  with  the  right  side  of  the 
abdominal  aorta  and  with  the  origins  of  the  middle  suprarenal,  the 
twelfth  intercostal,  and  of  the  first  lumbar  arteries. 

The  two  latter  vessels  may,  however,  pass  behind  the  thoracic 
duct.  Posteriorly,  the  duct  is  in  relation  with  the  body  of  the 
first  lumbar,  and  that  of  the  twelfth  dorsal.  On  the  right,  it  touches 
the  tendinous  border  of  the  right  pillar  of  the  diaphragm.  The 
vena  azygos  major,  which  is  more  external,  is  separated  from  it 
by  the  width  of  the  internal  portion  of  this  pillar.  To  the  left,  the 
duct  rests  on  the  loose  cellular  tissue  which  separates  the  abdominal 
aorta  from  the  longus  colli  muscle. 

THORACIC  PORTION. — The  thoracic  portion  may  be  regarded  as 
consisting  of  two  segments,  one  inferior,  or  inter-azygo-aortic,  and 
the  other  superior,  or  supra-azygo -aortic.  The  body  of  the  fourth 
dorsal  vertebra  marks  the  limit  between  these  two  segments. 

In  its  inter-azygo-aortic  segment,  the  thoracic  duct  is  in  relation 
behind,  with  the  vertebral  column,  from  which  it  is  separated  by  the 
right  intercostal  arteries  and  the  terminal  part  of  the  vena  azygos 
minor.  On  the  right,  it  is  in  relation  with  the  trunk  of  the  vena 


TERMINAL    COLLECTING    TRUNKS 


295 


a?,ygo3  major  ;  at  first  it  is  in  contact  with  this  vessel  at  the  level 
of  the  body  of  the  tenth  dorsal  vertebra,  it  then  gradually  passes  to 
its  side.  On  the  left,  it  is  in  relation  with  the  origin  of  the  left 
intercostal  arteries.  In  front,  it  is  in  relation  with  the  right  side 


Superior  cervical  ganglion 
I.rit  internal  carotid  urter 


1  hyroid  body 
Common  carotid  artery 


Inferi 


Aorta  — 

Left  p>i!>,,'-.n(iry  artery  - 

Left  lung  - 

Lt  it  bronchus  r~ 

7  horacic  dtict.  - 

Vugus  nerve 
Mediattinal  pleura 


Vena  azygos  minor 


•  Pharynx 
~  Superior  larynyeul 

Vagus  nerve 


In/.TH'il  jugular  vein 
Trachea 


>r  thyroid  artery 

Recurrent  laryngeul  ner, 
an  artery 


Innominate  vein 

Oesophagus 
Vagus  nerve 
Vena  uzyguf  major 
Iiro)fhial  artery 
Right  pulmonary  >:eit 
liight  lung 


Venz  cava  inferior 
Diaphragm 


FIG,    115. — Situation    and    connections    of    the    thoracic    duct    in    the    posterior 

mediastinum  (posterior  view). 

The  organs  of  the  neck  and  mediastina  have  been  reflected  and  displaced,  to  show  the 
different  levels.  On  the  left,  the  mediastinal  pleura  has  been  partly  preserved  and  hooked 
aside  to  show  the  pulmonary  pedicle  of  that  side  (adult). 

of  the  aorta,  and  then  with  the  posterior  surface  of  the  oesophagus, 
from  which  it  is  always  separated  by  a  space  of  5  to  G  millimetres. 
Higher  up,  when  it  begins  to  incline  to  the  left,  it  leaves  the  oesopha- 
gus, enters  into  relation  with  the  posterior  surface  of  the  hilum  of 
the  left  lung,  then  again  comes  in  contact  again  with  the  posterior 


296  SPECIAL    STUDY    OF    THE    LYMPHATICS 

surface  of  the  aorta,  at  the  junction  of  the  arch  and  commencing 
part  of  the  thoracic  aorta.  We  should  add  that  at  the  level  of  the 
fifth  or  sixth  dorsal  vertebra,  it  is  crossed  by  the  right  bronchial 
artery,  which  sometimes  passes  between  it  and  the  oesophagus, 
and  by  the  trunk  of  the  left  bronchial  vein  when  the  latter  passes 
into  the  azygos  by  a  retro-oesophageal  course. 

The  supra-azygo-aortic  segment  is  in  relation  :  behind,  with  the 
necks  of  the  first  three  ribs  which  separate  it  from  the  bodies  of  the 
first  three  dorsal  vertebrae  ;  in  front,  with  the  origin  of  the  left 
subclavian  artery  ;  internally,  with  the  oesophagus  and  left  recurrent 
laryngeal  nerve  ;  externally,  with  the  left  mediastinal  pleura. 

CERVICAL  PORTION. — The  cervical  portion  (the  terminal  bend  of 
the  thoracic  duct)  is  in  relation  :  beloiv,  with  the  trunk  of  the  sub- 
clavian which  it  crosses  at  the  spot  where  this  artery  inclines  out- 
wards to  turn  round  the  apex  of  the  lung  ;  behind  and  externally, 
with  the  inferior  cervical  ganglion,  and  origin  of  the  artery  and 
vertebral  vein  ;  in  front  and  internally,  with  the  left  common 
carotid  artery,  with  the  pneumo-gastric  nerve,  and  with  the  ter- 
minal part  of  the  internal  jugular  vein  (vide  Fig.  116). 

The  thoracic  duct  usually  terminates  at  the  actual  summit  of 
the  angle  open  above  and  externally,  and  formed  by  the  junction 
of  the  left  internal  jugular  and  subclavian  veins.  It  is  more  rare 
to  see  it  terminating  on  the  posterior  surface  of  the  venous  junction. 
We  shall  see  further  on,  when  studying  the  anomalies  of  the 
thoracic  duct,  that  the  termination  of  this  canal  by  two  distinct 
branches  is  fairly  frequent. 

VALVES. — The  thoracic  duct  has  but  few  valves,  and  those  it  has 
are  usually  inefficient.  There  are,  however,  at  the  opening  of  the 
duct  into  the  venous  junction,  two  well  developed  valves  which 
prevent  the  venous  blood  from  flowing  back  into  the  thoracic  duct. 

AFFLUENTS. — The  affluents  of  the  thoracic  duct  may  be  divided 
into  two  groups  ;  some  of  them  unite  to  give  origin  to  this  duct, 
and  form  for  it,  true  radicular  branches  ;  others  terminate  in  the 
already  formed  duct,  and  are  collateral  branches. 

(A)  Roots  of  the  Thoracic  Duct. — The  thoracic  duct  is  formed  by 
the  union  of  the  efferent  vessels  of  the  four  glandular  chains  : 
viz.  the  prae-aortic,  the  retro-aortic,  and  right  and  left  juxta- 
aortic.  The  mode  of  convergence  of  these  vessels  is  very  variable. 
The  arrangement  which  we  have  found  the  most  frequent  is  as 
follows  :  The  efferent  vessels  of  each  juxta-aortic  group  unite 
into  a  large  trunk  (truncus  lymphaticus ,  lumbal.  dext.  et  sinist., 


TERMINAL    COLLECTING    TRUNKS 


297 


Longus  colli 
Common  carotid 
Pneumogasiric 

Vertebral  artery 

Vertebral  vein 
Thoracic  duct 


-•Internal  jugular  vein 


•  Anterior  jugular  vein 


Henle)  which  appears  at  the  sides  of  the  body  of  the  twelfth 
lumbar  vertebra.  The  two  trunks  right  and  left,  thus  formed  run 
upwards  and  inwards 
and  unite  at  an  acute 
angle  on  the  anterior 
surface  of  the  verte- 
bral column  to  give 
origin  to  the  thoracic 
duct.  On  account 
of  the  slightly  in- 
clined position  to 
the  right  at  which 
these  vessels  unite, 
that  on  the  left  side 
is  usually  longer  and 

more     oblique      than  FIG.  11G.— Terminal  bend  of  the  thoracic  duct. 

that    on    the   right. 

The  efferent  vessels  of  the  prae-  and  retro-aortic  glands,  the 
number  of  which  is  very  variable,  empty  themselves  into  the 
two  preceding  trunks,  in  the  region  of  their  termination.  The 
thoracic  duct  then  appears  as  though  formed  by  the  junction  of 
two  lateral  roots,  which  are  themselves  enlarged  by  receiving  a 
greater  or  less  number  of  affluents  (vide  a,  Fig.  117). 

This  arrangement,  however,  is  far  from  being  constant ;  thus 
we  may  frequently  see  afferent  vessels  of  the  prae-aortic  group  give 
origin  to  a  single  trunk  (truncus  lymph,  intestinalis)  which  empties 
into  one  of  the  large  lateral  trunks,  or  ends  at  the  same  level  as 
their  point  of  convergence,  thus  forming  a  third  uneven  and  median 
root  of  the  thoracic  duct  (vide  b.  Fig.  117).  Several  authors,  and 
notably  Sappey  and  Henle,  regard  this  latter  arrangement  as 
corresponding  to  the  normal  type. 

(B)  Collateral  Branches. — The  thoracic  duct  receives  as  collateral 
branches  : 

(1)  A  descending  trunk,  which  is  the  common  collector  of  the 
efferent  vessels  of  the  posterior  intercostal  glands  of  the  six  or  seven 
lower  spaces.     This  trunk  terminates  in  the  thoracic  duct  near  its 
origin.     Thus  some  authors,  as  Sappey,  regard  this  vessel  as  one 
of  the  roots  of  the  thoracic  duct. 

(2)  A  trunk  formed  by  the  junction  of  several  vessels  coming 
from  the  superior  glands  of    the  two    juxta-aortic    chains,    right 
and  left.     This  trunk  traverses  the  pillar  of  the  diaphragm  and 


298 


SPECIAL    STUDY    OF    THE    LYMPHATICS 


empties  itself  into  the  thoracic  duct  at  the  level  of  the  ninth  or 
the  tenth  dorsal. 

(3)  The  efferent  vessels  of  the  intercostal  glands  of  the  first  five 
or  six  spaces. 

(4)  The  efferent  vessels  of  the  posterior  mediastinal  glands. 


FIG.  117. — Modes  of  origin  of  the  thoracic  duct. 

o.  Thoracic  duct.  a'.  Receptaculum  chyli.  6.  Common  trunk  of  the  efferents  of  the 
right  juxta-aortic  glands,  c.  Common  trunk  of  the  efferents  of  the  left  juxta-aortic  glands. 

d.  One  of  these  efferents  passing  into  the  thorax  through  the  left  pillar  of  the  diaphragm. 

e.  Right     juxta-aortic     gland.      /.  Left     juxta-aortic     gland,     h.  Retro-aortic     gland.      »'. 
Common  trunk  of  prae-aortic  glands  (truncus  intestinalis).     j.  Collecting  trunk  of  the  inter- 
costal lymphatics,  which  reaches  the  receptaculum  chyli  by  taking  a  downward  course. 

Finally,  we  have  seen  that  the  left  jugular  trunk  and  much  more 
rarely  the  sub-clavian  and  the  corresponding  broncho-mediastinal 
trunk  may  terminate  in  the  thoracic  duct  near  its  termination. 

On  the  STRUCTURE  and  DEVELOPMENT,  vide  pp.  67,  75. 

Technique. — To  study  the  thoracic  duct  it  is  essential  to  inject  it.  In 
the  adult,  the  duct  may  be  directly  injected.  The  method  of  procedure  is 
as  follows  :  First  of  all,  the  thoracic  duct  must  be  obliterated  at  its  terminal 
segment,  and  for  this  purpose  the  ligature  may  be  used  ;  but  this  is  a  diffi- 
cult procedure  and  the  same  result  may  be  much  more  easily  obtained  by 
simply  injecting  tallow  grease  into  the  subclavian  vein.  We  then  look  for 
the  origin  of  the  thoracic  duct.  After  removing  the  abdominal  viscera,  the 
right  side  of  the  abdominal  aorta  is  cleaned  at  the  level  of  the  second  lumbar 
vertebra,  and  this  vessel  is  turned  to  the  left.  The  receptaculum  chyli  is 
then  found  lying  immediately  internal  to  the  right  pillar  of  the  diaphragm. 
The  duct  may  be  injected  with  mercury  with  the  ordinary  apparatus  ;  but 
it  is  preferable  to  inject  with  tallow  grease  or  gelatine,  using  the  same  method 
as  that  employed  for  the  blood  vessels.  We  advise  the  canula  being  placed 
not  in  the  duct  itself,  but  in  its  right  root,  for  by  so  doing  we  nearly  always 
obtain  an  injection  of  the  other  roots  by  regurgitation.  It  is  essential  to 
make  use  of  a  somewhat  low  pressure,  for  the  duct  easily  breaks,  especially 
near  its  origin.  To  facilitate  the  progress  of  the  injected  material  it  is 


TERMINAL    COLLECTING   TRUNKS  299 

useful  to  fill  the  thoracic  cavity,  from  which  the  contained  viscera  have  been 
removed,  with  hot  water. 

In  the  new-born,  the  direct  injection  of  the  canal  is  impossible,  but  it  can 
easily  be  filled  by  injecting  Gerota's  mass  into  the  glands  of  the  abdomino- 
aortic  group  ;  in  this  way  an  injection  of  all  the  roots  of  the  canal  may  be 
obtained,  and  this  method  of  procedure  yields  the  happiest  results  for  the 
study  of  these  roots.  In  the  new-born  we  have  often  filled  the  thoracic 
duct  as  far  as  its  terminal  bend  by  injecting  the  lymphatics  of  the  testicle 
and  uterus. 

ANOMALIES  or  THE  THOKACIC  DUCT. — The  description  we  have  given  of  the 
thoracic  duct  corresponds  with  what  is  met  with  in  the  majority  of  cases  ; 
but  the  anomalies  of  this  canal  are  extremely  frequent,  and  we  have  here 
once  again  the  proof  of  what  we  stated  at  the  beginning  of  this  section, 
namely,  that  the  lymphatic  is  the  most  variable  .of  all  the  systems.  Though 
the  number  of  anomalies  is  almost  infinite  we  may  group  them  in  some  of 
the  following  categories  : — 

(1)  Anomalies  of  course  and  relations. 

(2)  Anomalies  of  number. 

(3)  Anomalies  of  termination. 

We  may  observe  however,  at  once,  that  these  different  categories  do  not 
exclude  one  another  and  that  they  combine,  giving  rise  to  as  many  different 
types. 

(1)  ANOMALIES  OF  COURSE  AND  RELATIONS. — As  regards  the  aorta,  the  thoracic 
duct  may  be  placed  on  the  anterior  surface  of  this  vessel,  instead  of  on  its 
posterior  surface. 

As  we  have  already  seen,  the  majority  of  the  thoracic  branches  of  the 
.aorta  pass  behind  the  thoracic  duct.  According  to  Haller  (Disp.  Anat. 
HaUeri,  p.  197,  vol.  i.),  the  intercostals  pass  sometimes  in  front  of,  arid  some- 
times behind  the  thoracic  duct.  Saltzmann,  however,  on  the  contrary,  in 
his  thesis  (p.  178,  Fig.  1),  represents  them  as  always  passing  in  front,  which  is 
clearly  an  error. 

The  relations  with  the  large  vessels  of  the  upper  part  of  the  thorax  and 
of  the  base  of  the  neck  vary  according  to  the  mode  of  termination  of  the 
thoracic  duct,  and  these,  together  with  the  anomalies  of  the  termination  of  the 
duct,  we  will  study  later  on. 

One  of  the  most  variable  features,  however,  of  the  topography  of  the 
thoracic  duct  is  the  situation  of  its  terminal  bend.  M.  Dorvel  (T odd's 
Encyclop.,  vol.  iv.,  plate  2,  p.  823)  shows  this  terminal  segment  reaching 
the  inferior  thyroid  artery,  crossing  its  posterior  surface  and  passing  above 
this  artery  to  terminate  in  the  subclavian  vein.  According  to  Dietrich 
(Das  Aufsuchen  der  Schlagadern,  Niirnberg,  1831,  p.  154),  the  summit  of  the 
bend  may  be  more  than  five  centimetres  above  the  sternal  notch,  and  reach 
as  far  as  the  inferior  border  of  the  thyroid  body.  Other  authors,  on  the 
contrary,  describe  it  as  barely  reaching  the  base  of  the  neck.  In  fact,  the 
highest  point  of  the  terminal  bend  of  the  thoracic  duct  lies  at  varying  levels 
between  the  fifth  cervical  and  the  first  dorsal  vertebra. 

(2)  ANOMALIES  IN  NUMBER. — Nothing  is  commoner  than  to  see  the  thoracic 
duct  bifurcate  into  two  branches  which  unite  after  a  longer  or  shorter  course, 
enclosing  between  them  a  space  to  which  Haller  (Physiology,  p.  220)  gives 
the   name   of   insula.     This   arrangement   is   so   frequent   that   Cruikshank 
(loc.  cit.,  p.  330)  describes  it  as  normal.     Though  lying,  in  the  majority  of 
cases,  at  the  level  of  the  thoracic  portion  of  the  canal,  these  insulae  may  also 


300  SPECIAL    STUDY    OF    THE    LYMPHATICS 

occupy  its  superior  extremitjr.  The  form  and  dimensions  of  these  insulae 
are  very  variable  ;  they  are  usually  elongated,  oval  or  lozenge  shaped.  In 
some  cases,  one  or  several  small  transverse  aiiastomotic  branches  may  be 
seen  uniting  the  two  branches  limiting  the  insula  (Breschet).  In  others,  the 
duct  divides  into  several  branches  which  converge  towards  one  another, 
giving  origin  to  double  or  multiple  insulae.  In  other  cases  again,  of  these 
two  divisional  branches,  one  remains  single,  while  the  other,  on  the  contrary, 
ramifies  and  gives  rise  to  several  secondary  insulae  ;  then  the  small  branches 
reunite  into  a  single  trunk  which  unites  with  the  branch  which  has  remained 
undivided  and  reconstitutes  the  single  thoracic  duct  (Breschet,  Th.  cVagrega- 
tion,  p.  246). 

These  arrangements  do  not,  however,  properly  speaking,  constitute 
multiple  thoracic  ducts.  Nuhn  (Unters  und  Beobacht  ad  Gebiete  der  Anatomie, 
Heidelberg,  1849,  p.  25)  describes  a  very  clear  case  of  a  double  thoracic  duct 
with  a  right  trunk  situated  to  the  right  of  the  aorta,  and  a  left  trunk  situated 
to  the  left  of  this  vessel,  and  united  one  to  the  other  by  transverse  anasto- 
moses. In  the  upper  part  of  the  thorax,  the  two  canals  united,  passed  in 
front  of  the  innominate  vein,  then  curved  behind  the  internal  jugular  vein 
and  passed  into  the  angle  which  this  vein  forms  with  the  sub-da  via  n. 
Henle  cites  a  case  where  the  thoracic  duct  was  double  as  high  up  as  the  level 
of  the  ninth  dorsal  vertebra  ;  here  the  two  ducts  joined,  and  formed  a  single 
trunk  which  was  placed  on  the  left  of  the  aorta  and  continued  its  course  in 
this  situation. 

These  multiple  thoracic  ducts  may  terminate  in  manj-  different  ways  ; 
thus  they  may  unite  into  a  single  trunk  terminating  in  the  left  sub-clavian  as 
in  the  two  preceding  cases,  or  in  the  sub-clavian  of  the  right  side  (Otto, 
Pathol.  Anat.,  vol.  i.  p.  365),  or  they  may  remain  separate,  the  right  receiving 
the  right  lymphatic  duct,  and  passing  into  the  right  sub-clavian,  and  the 
left  into  the  left  sub-clavian  (Walther,  Haller,  Homel,  Cruikshank,  Sommer- 
ing,  Otto). 

The  anomalies  of  number  of  the  thoracic  duct  at  its  terminal  portion  are 
intimately  connected  with  the  anomalies  of  its  termination  and  will  be 
studied  with  them. 

(3)  ANOMALIES  OF  TERMINATION. — We  have  already  seen  that  the  thoracic 
duct  most  frequently  ends  in  the  left  sub-clavian  vein,  in  the  angle  which 
this  vessel  forms  with  the  internal  jugular.  Abnormally  it  may  end  in  the 
subclavian  vein  external  to  this  point.  Sometimes  we  may  see  the  terminal 
part  of  the  bend  divide  into  two  trunks  which  terminate  separately  by  two 
orifices  in  the  sub-clavian  vein.  (Saltzmann,  Meckel,  Haller.) 

Much  more  rarely,  the  thoracic  duct  remains  undivided  and  terminates 
in  the  subclavian  of  the  right  side.  In  these  cases  the  right  lymphatic  duct 
empties  into  the  left  subclavian  (Meckel,  Diss.  Epist.  ad  Haller,  Berol,  1772, 
p.  30.  Haller,  Elem.  Physiologiae,  vol.  vii.,  p.  223.  Cruikshank,  Fleichmann, 
Leichenoffnungen,  Erlangen,  1815,  p.  237.  Todcl,  Encyclopedia,  vol.  iii., 
p.  232.  Watson,  Journ.  of  Anat.,  vol.  vi.,  p.  427). 

It  is  quite  exceptional  to  see  a  single  thoracic  duct  terminate  in  a  vein  at 
the  base  of  the  neck  other  than  the  left  subclavian  vein.  Portal  and 
Richerand,  however,  each  mention  a  case  where  the  thoracic  duct  passed 
into  the  right  internal  jugular  ;  but  what  is  much  more  frequently  met  with, 
is  a  division  of  the  terminal  segment  of  the  thoracic  duct  into  one  or  more 
trunks  which  terminate  in  different  veins. 

Thus  Diemerbroek,  A.  Cloquet  and  E.  A.  Lauth,  and  Cruveilhier  describe 
cases  of  bifurcation,  in  which  one  branch  passed  into  the  right  subclavian, 


TERMINAL    COLLECTING    TRUNKS  301 

while  the  other  passed  into  the  left.  Mascagni,  Bichat,  Cruveilhier  also 
noted  the  division  into  two  branches,  one  of  which  passed  into  the  sub- 
clavian,  the  other  into  the  internal  jugular  of  the  left  side.  This  terminal 
division  is  described  as  normal  by  Lower  (De  Corde,  Lugd.  Batav..  1728, 
p.  233). 

The  division  into  three  or  four  branches  has  been  pointed  out  by  Verneuil 
(Le  Systeme  Veineux,  1855),  who  gives  the  following  proportions:  In  twenty- 
four  cases,  the  opening  was  eighteen  times  single,  three  times,  double,  and 
twice,  triple.  The  same  author  reports  a  case  of  a  sixfold  terminal  division 
of  the  thoracic  duct,  two  branches  of  which  went  to  the  subclavian,  two 
to  the  external  jugular,  and  one  to  the  vertebral.  The  Society.  (Traite 
a"  anatomic,  Paris,  1853)  reports  a  case  of  quadruple  division. 

With  this  question  of  the  anomalies  of  the  termination  of  the  thoracic 
duct,  is  connected  the  study  of  communications  of  this  duct  with  veins 
other  than  the  great  trunks  at  the  base  of  the  neck.  Albinus  as  well  as 
Sandford  describe  communications  with  the  azygos.  Wutzer  also  mentions 
similar  cases.  Gayaut,  Pecquet  and  Perrault  have  seen  communications 
with  the  lumbar  veins  ;  finally  Bartholin  mentions  a  case  of  communication 
between  the  thoracic  duct  and  the  vena  cava.  According  to  Henle,  who 
lias  subjected  all  these  facts  to  severe  criticism,  only  one  of  them  is  undeniable, 
namely  the  case  reported  by  Wutzer  in  the  Archives  de  M«7Zer  (1834,  p.  311). 
This  was  a  case  of  the  thoracic  duct  ending  in  the  azygos  vein  in  the  neigh- 
bourhood of  the  sixth  dorsal  vertebra  by  two  trunks  which  ascended 
obliquely  and  ran  parallel.  Above  this  point  the  thoracic  duct  was  obli- 
terated. Whether  this  obliteration  was  congenital  or  acquired,  it  seemed, 
as  Wutzer  stated,  that  this  communication  existed  previously  to  the 
obliteration. 

The  majority  of  these  anomalies  are  normally  found  in  certain  mammals  ; 
thus  in  the  horse,  the  thoracic  duct  is  double  up  to  the  junction  of  the  pos- 
terior two-thirds  and  the  anterior  third  (Colin).  In  the  ox,  the  terminal 
segment  of  the  thoracic  duct  assumes  a  plexiform  aspect.  This  plexiform 
arrangement  may  be  found  throughout  the  whole  extent  of  the  duct  in 
certain  marsupials  (Hodgkin).  As  a  matter  of  fact  these  isolated  observa- 
tions are  not  of  much  interest.  The  writings  we  possess  on  the  comparative 
anatomy  of  the  thoracic  duct  are  still  too  few  to  enable  us,  even  approxi- 
mately, to  formulate  our  knowledge  of  its  phylogenic  evolution. 


Butler  &  Tanner,  The  Selwood  Printing  Works,  Frome,  and  London. 


Lj 


- 
cist*      \ 


o 


in 


\ 


,0 


/  r*i 


La_J 


y 
^/  ^v>i9n   V- 

V^*   otiwvufwQ    \< 

/(,^      -3    i     ^^ 


/rn 


^          r-*-i  c^ 


"o 

gn  '< 


o 


V 

* 


cj/r      \^~*/'  xWagn  \J-3.^ 
UC          %  J"  /•>       \    3 

J~       ;Cf          V        Q&WVjfwC)       +*.f 
w,  rranrifm       .&  <,.  A         ^  h. 


/  ^^^x^y1.^ 

**/'*&? 


;  <ss^»  x  "*^  X  ^^ 

°*.         I100AOV         .^ %.  4/fZj  /r*-|      *       LIBR^ 


-V    LIBRARY  /  p-j  \ 


- 
ftranajco 


fx       I     jl  _,          .^  t  s^ 

V    ^    v ' 

OtfL 


\  / 
<i* 

&  4. 


551278 


3   1378  00551    2788    ^^^ 


\c^/°  ciuC  X1^- 

^      v^                 ^14^  9p        ^s 

•^    ^  ^      C    zr  %  4s 

^   ^       £^  .^  ^>. 


LIBRARY          r- 


